To link to the entire object, paste this link in email, IM or documentTo embed the entire object, paste this HTML in websiteTo link to this page, paste this link in email, IM or documentTo embed this page, paste this HTML in website

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
Choosing the Right Words, the Right Place,
and the Right Time .........................................1
From the Executive Director:
Feedback .........................................................1
Dialogue on Public Health.................................3
NCMB Announces Hiring New Medical
Coordinator: Gary M. Townsend, MD, JD ....5
Battered Men: Another Story .............................6
Using the NCMB’s DataLink Software ..............7
Position Statement on Office-Based Surgery.......7
Prescriptions: Legal and Legible.........................8
From the NC Board of Pharmacy:
Focus on Prescriptions .......................................9
Treating Bias ....................................................10
President’s
Message
From the
Executive
Director
Wayne W. VonSeggen, PA-C Andrew W. Watry
No. 3 2000
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Choosing the Right
Words, the Right Place,
and the Right Time
The Right Words
In the work of the North Carolina
Medical Board, we are challenged to license
and discipline and to properly regulate the
practice of medicine and surgery in North
Carolina for the benefit and protection of
the public. In the position statements and
the various motions that the Board considers
and acts upon, the Board must carefully and
cautiously use the appropriate words to con-vey
the principles involved. The Board often
attempts to clarify the words by defining
them with great precision. Some of the
more challenging words recently addressed
have been “injection,” “surgery,” “invasive
procedure,” “scope of practice,” “compe-tence,”
and “continuing medical education.”
In the area of scope of practice, the Board
accepts the fact that, more often than not,
the scope of practice for a given profes-sion
has already been
determined by the
North Carolina Gen-eral
Assembly, and
codified in statute,
with regulations to
clarify the remain-ing
issues. Sometimes,
the General Assembly
has chosen to leave
certain issues unde-fined,
with some pro-fessions
struggling to
implement their own nationally promulgat-ed
and hopefully successful scope of practice.
Occasionally, when new professions arrive
on the health care scene, there is inevitable
overlapping of skill bases. Often these can
be worked out on a national basis, with indi-vidual
professions hoping to stake a claim to
a particular “scope of practice” by their own
definition. In North Carolina, we have
recently experienced significant differences
Feedback
This article appears opposite a message
from the Board’s president, Mr Wayne
VonSeggen, which, in this instance, is
particularly poignant for me. His topic,
choosing words carefully, covers an area to
which I need to devote some attention. So,
in an abundance of caution, I consulted
Merriam-Webster’s Collegiate Dictionary. The
first definition of feedback is: “the return to
the input of a part of the output of a
machine, system, or process (as for produc-ing
changes in an electronic circuit that
improve performance or in an automatic
control device that provide self-corrective
action).” The Board may be viewed as a
control device for public protection, man-dated
by the public
through legislation.
A similar device
exists in our 49
constituent states,
as well as a majori-ty
of countries and
other political sub-divisions
through-out
the world.
In our jurisdiction, we pay particular
attention to feedback. This is done through
a variety of mechanisms. The principal
mechanism is the work of the Board’s Public
Affairs Department, of which this publica-tion,
the Forum, is a major product. Another
important element of that department’s
activity is the posting of public information
for consumers and licensees both on the
printed page and on our Web site. Feedback
is vitally important to the Board, allowing us
to identify and implement self-corrective
action.
forum
continued on page 3
continued on page 2
A Brief Guide to CME Requirements for
Physicians in North Carolina........................10
The Physician Assistant ....................................13
Letters to the Editor:
Legislation Is the Best Solution to Records Problem;
And More on Medical Records;
Male Victimization........................................14
Vital Information Required by the NCMB.......15
Review:
Doctor Death: The Ultimately Impaired
Physician.......................................................16
Explore the NCMB’s Web Site .........................18
Board Actions: 5/2000-7/2000 ........................19
Board Calendar ................................................23
Change of Address Form..................................24
License Registration .........................................24
POSITION STATEMENT ON
OFFICE-BASED SURGERY – PAGE 7
BRIEF GUIDE TO NCMB
CME REQUIREMENTS – PAGE 10
“Feedback is
vitally important
to the Board,
allowing us to
identify and
implement self-corrective
action”
“In North
Carolina, we
have recently
experienced sig-nificant
differ-ences
of opinion
about ophthal-mology
and
optometry scopes
of practice”
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. V, No. 3, 2000
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Wayne W. VonSeggen, PA-C
President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Vice President
Raleigh
Term expires
October 31, 2002
Walter J. Pories, MD
Secretary-Treasurer
Greenville
Term expires
October 31, 2000
George C. Barrett, MD
Charlotte
Term expires
October 31, 2002
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2001
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Paul Saperstein
Greensboro
Term expires
October 31, 2001
Aloysius P. Walsh
Greensboro
Term expires
October 31, 2000
Martha K. Walston
Wilson
Term expires
October 31, 1999
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Assistant Editor
Shannon L. Kingston
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.ncmedboard.org
E-Mail:
info@ncmedboard.org
Choosing the Right Words
continued from page 1
of opinion about ophthalmology and
optometry scopes of practice, primarily
regarding whether an injection should or
should not be considered surgery. The
optometry statute specifically excludes
surgery from the scope of practice of optom-etry.
The North Carolina Medical Board
continues to work toward a clearer under-standing
between these groups of highly
skilled health care practitioners. It is a work
in progress.
Conceptually, scope of practice is different
from the standard of care, which more accu-rately
describes what is currently being done
in a certain locality. When the standard of
care for a profession exists, can it ever
change? Is the standard of care a local phe-nomenon?
Or is it a statewide phenome-non?
Or is it, finally, determined nationally?
When a possible change in the standard of
care for a particular profession is acknowl-edged,
from whose perspective is that stan-dard
of care determined: the professionals
who support the new standard or the aver-age
citizen-patient? Scope of practice, being
defined principally by statute, is more than a
wishful expectation, it is a legal boundary
that requires careful analysis of the law as
well as issues such as training, experience,
and public safety.
At issue is the responsibility and duty of
regulatory boards themselves. How far can
the regulatory board proceed with defin-ing
words, concepts, and overlapping scopes
of practice while still
performing the pri-mary
function of
protecting the pub-lic?
While each profes-sion
seeks to carve
out its niche in the
health care arena,
there is potential
conflict ahead when one profession signifi-cantly
infringes on the scope of another. If
the General Assembly does not provide clear
definitions, the responsibility could arrive
back at the door of the North Carolina
Medical Board, which has been given the
authority to regulate the practice of medi-cine
and surgery. So far, the Board has taken
what it considers to be thoughtful and
responsible actions in various areas affecting
physicians, surgeons, physician assistants,
nurse practitioners, nurse midwives, EMS
personnel, resident physicians, and other
health professions, such as clinical pharma-cist
practitioners, optometrists, and pharma-cists.
The Right Place
Take your pick...a court of law, the legisla-ture,
the professional organization, or the
regulatory board? At one time or another,
each of these has driven decision-making on
particular issues. For example, in 1997,
under Senate Bill 945, the General Assembly
directed that “drugs identified as having nar-row
therapeutic indices shall be designated
by the North Carolina Secretary of Human
Resources upon the advice of the State
Health Director, North Carolina Board of
Pharmacy, and the North Carolina Medical
Board.” As a result, each year the process of
identifying those drugs that fit into this cat-egory
falls to those entities given authority
by statute. The Board is aware that the leg-islature
may choose to write statutes that
direct one or more regulatory boards to
work out the regulatory details of a particu-lar
issue.
The North Carolina Medical Board urged
passage of House Bill 1049 in the 1999 and
2000 sessions of the General Assembly to
attempt to improve the ability of the Board
to properly regulate and discipline physi-cians
and to make the unlicensed practice of
medicine a felony instead of a misdemeanor.
However, the General Assembly balked on
the latter point when a cadre of naturopath-ic
and homeopathic practitioners and their
supporters voiced vehement opposition to
it. Legislators heard the unlicensed practi-tioners
talk publicly about their practices,
knowing that those practitioners have no
statutory basis for practice in this state at this
time. Not a single legislator publicly
remarked about the lack of statutory author-ity
in North Carolina to practice naturopa-thy
or homeopathy. Grassroots activism,
including e-mail, letters, and telephone calls,
forced modification of the bill on that issue.
And finally, the entire bill died for lack of
action by the Senate.
Six years ago, when optometrists strove to
include 150 additional CPT codes in their
scope of practice, the ophthalmologists and
other physicians and surgeons, and even the
Medical Board, became active at the judicial
level to block such action. To resolve such
attempts to expand the scope of optometry,
a Consent Agreement was signed under
which such changes must be approved by all
the disputing parties that signed the agree-ment,
including the Medical Board. Since
then, further requests for modification of
continued on page 3
“There is poten-tial
conflict
ahead when one
profession signif-icantly
infringes
on the scope of
another”
No. 3 2000 3
Feedback continued from page 1
Legislative Lessons Learned
An example of self-corrective action is
found in the Board’s recent attempt to bring
improvement to its statutory foundation, the
Medical Practice Act (MPA). Under North
Carolina law, the Board cannot use any funds
to promote or oppose legislation. It must,
therefore, rely on legislative leadership to
shepherd corrective actions. Unfortunately,
while the Board’s legislative initiative
(House Bill 1049) passed the House in this
last session, it died in the Senate due to
strong opposition to the bill in that chamber.
The Board will be evaluating the feedback
from this process to determine how best to
achieve in the next legislative session the
improved approaches to public protection it
seeks. The following is some feedback gen-erated
in the course of this recent legislative
experience.
The Board sought to make the penalty
for the unlicensed practice of medicine a
felony instead of a misdemeanor. There
was substantial opposition to this provision
from supporters and practitioners of so-called
alternative medicine. Some of these
were duly licensed
physicians. The
legislation was per-ceived
as a threat to
alternative medi-cine.
In actuality,
the legislation did
not change in any
way what consti-tutes
legal or illegal
behavior by unli-censed
persons. It
only changed the penalty for engaging in
such illegal behavior. The legislation, how-ever,
was painted as an attack on practices
such as naturopathy and homeopathy.
There are no naturopathic or homeopathic
licensing statutes in North Carolina, and,
thus, there are no licensing boards for
naturopathy and homeopathy. Yet, several
persons identifying themselves as natur-opaths
testified about the validity of their
practices and the threat presented by
increasing the penalty for their unlicensed
activities.
In the House, there was an amendment to
HB 1049 to set up a legislative research
commission to look at all the issues con-cerning
these various unlicensed practition-ers,
but the amendment, along with HB
1049, died in the Senate. The feedback we
received in connection with this legislative
optometry’s scope of practice have surfaced
periodically. However, due to the Consent
Agreement, unless every party to the agree-ment
approves, NO CHANGE CAN TAKE
PLACE! One has to wonder whether such
an agreement is the right vehicle for the
determination of the scope of practice, or
whether it is time for the General Assembly
to clarify its intent concerning the scope of
practice of optometry.
Political powers should tread gently in
determining the scope of practice of health
care professions, especially when ethical con-siderations
in government cry out for fair
play and equal rights for everyone’s profes-sion.
Regulatory boards derive all their
authority from legislatures. Hence, regula-tory
boards should stay within their areas of
responsibility.
The convergence of events sometimes
enlightens us to the irony of these endeav-ors.
Within the same month the North
Carolina Medical Board heard ophthalmolo-gists
state that there was no possible way
that an injection in any form by an
optometrist could be considered within the
scope of practice of optometry, we heard
pharmacists asking for the ability to expand
their scope of practice to give multiple types
of injections at pharmacies, outside the
purview of the patient’s personal physician.
Thousands of insulin-regulated diabetics
inject themselves every day in North
Carolina and no one has considered this to
be “practicing surgery.” Nurses provide
injections regularly with skill and predictably
excellent outcomes for millions of our citi-zens
and it is not considered “practicing
surgery.” This all brings me to the last point.
The Right Time
Medical knowledge marches on. Modern
medical technology will always push us to be
faster, more precise, more efficient, with
higher quality and improved outcomes.
That is the nature of progress. Every med-ical
professional struggles to keep up with
the ever-expanding database and skill
requirements in medicine. Do our continu-ing
education attempts really ensure our
competence? Do the acquired skills you
have learned since your graduation from
professional school mean anything? Of
course they do! Your database is better, and
your skills are at a higher level. Are the skills
you have acquired since your licensure as a
health professional of any real value? Of
course they are! Does all this medical train-ing
after licensure or after graduation affect
your scope of practice? It all depends on
whom you ask! Some say, “Training does
not necessarily change your scope of prac-tice.”
The easy answer is to agree that if you
really do know what you’re doing in your
specific piece of the medical specialty you
practice, then you will likely be able to pull
it off. You provide top-notch health care ser-vices,
probably within your scope of practice
and standard of care. You feel comfortable.
The patient gets good service. Everyone is
happy...unless you have trodden into anoth-er
profession’s scope of practice. You may
then need to look to your attorney for guid-ance,
or call your legislator and get everyone
else to do the same. Remember that democ-racy
is the will of the people, but there are
definitely principles involved. Grassroots
activism cannot totally obviate principle.
The Medical Board works to balance the
issues on the principles involved in our pro-gressive
medical environment. The Board
believes that it has the authority to regulate
the practice of medicine and surgery and to
refer for legal action any situation that might
be considered the unlicensed practice of
medicine. Sometimes we take action, and
sleep soundly. Other times, we second-guess
ourselves, review issues again, and strive for
the solution. Jim Elliott, a missionary to the
Auca Indians in Peru, once said, “Indecision
is the true enemy of successful perfor-mance.”
At times, we push to make a deci-sion
and must reconsider certain actions in
light of additional information. The strug-gle
is to use the right words, in the right
place, and at the right time.
Choosing the Right Words
continued from page 2
continued on page 4
“It seems pru-dent
to separate
the issues affect-ing
unlicensed
people from the
issues of improv-ing
the process
for licensed
physicians”
Dialogue on Public Health
Public health issues are a concern, not only
for the medical community, but also for indi-viduals
and families across North Carolina.
Now there’s a forum to discuss many of
those issues and to provide accurate, up-to-date
information to the public as well. A 12-
month series of call-in programs on the
Open Public Events Network (OPEN)
begins with a discussion about asthma on
November 16 at 9:00 PM. The call-in series,
which is sponsored by the Division of Public
Health, Department of Health and Human
Services, will continue on the second
Thursday of every month at 9:00 PM on var-ious
public health topics.
OPEN programs give citizens an opportu-nity
to call in and talk with public officials
about a broad range of topics of statewide
interest every Tuesday and Thursday from
8:00-10:00 PM. For a list of cable systems
carrying OPEN programs, including
the series on public health, or to receive
monthly program schedules, call 919-733-
6341, e-mail open@ncmail.net, or go to
www.doa.state.nc.us/doa/apt/cablelst.htm.
effort seemed to paint the Board as a group
of physicians trying to protect its turf and
exclude so-called alternative medical practi-tioners
from the market place. From the
Board’s perspective, this is certainly not the
case. The Board recognizes the significant
marketplace in alternative medicine (by
some estimates, a 4 billion dollar a year
enterprise) and the importance of physi-cians
having a working knowledge of alter-native
medical practices (many of
their patients may be taking alter-native
substances that can inter-act
with prescribed medicines).
The Board was simply concerned
that there are individuals engag-ing
in activities that are defined in
the MPA as the practice of medi-cine
who have had no screening
and validation for training cre-dentials,
have passed no licensing
examination, and have no licens-ing
board as a recourse for consumers who
are dissatisfied or in some way harmed. In
short, they are in violation of the MPA.
These individuals are unaffected by the
penalty for unlicensed practice as it now
exists and the Board proposed a remedy. As
I’ve noted, there was a significant backlash
in the legislature to this proposed remedy.
The Board is reassessing what consumers
in this state expect from its licensing system
and whether the Board or some other enti-ty
should be the catalyst for corrective
action in light of substantial consumer
response. Unfortunately, this consumer
response had the effect of chilling the
Board’s recommended improvements in
other important areas with respect to pub-lic
protection mechanisms involving physi-cian
licensees. The Board will deliberate
over the lessons learned. At the very least,
it seems prudent to separate the issues
affecting unlicensed people from the issues
of improving the process for licensed physi-cians.
Pain Management and Drug-Seekers
The Board members and staff spend a lot
of time giving speeches to various organiza-tions
such as hospitals, medical societies, and
consumer groups. This provides a valuable
feedback mechanism. The following is an
example of feedback from some recent activ-ities.
The Position Statements of the North
Carolina Medical Board includes a state-ment
on the management of chronic non-malignant
pain. The beginning of that
statement reads: “It is becoming increas-
4 NCMB Forum
Feedback
continued from page 3
ingly apparent to physicians and their
patients that the use of effective pain man-agement
has not kept pace with other
advances in medical practice.” It goes on to
define pain categories and appropriate
mechanisms for treating chronic pain,
including a list of 11 suggested elements
for effective management. It ends with the
comment that no physician need fear
reprisals from the Board for appropriately
prescribing, as outlined in the statement,
even large amounts of controlled sub-stances
indefinitely for chronic non-malig-nant
pain. This position state-ment
is consistent with national
recommendations and guidelines
intended to sensitize physicians to
suggestions that chronic non-malignant
pain may be inade-quately
medicated by some physi-cians
who fear medical board
intervention.
When presented to practitioners
in the field, including hospital
physicians and pharmacists, this
statement is well received, but there is feed-back
about a real-life situation that
also plagues these practi-tioners:
professional drug-seek-ing
patients. The existence of
these so-called patients in all
state medical board jurisdic-tions
is well documented. They
are particularly well document-ed
in states where there are trip-licate
prescription programs
documenting their activity, such
as seeking controlled substances
from several physicians and
pharmacies simultaneously.
An example of a patient
encounter that presented a
dilemma for a practicing physician was
raised at a recent meeting. A physician
described a patient he suspected was abus-ing
controlled substances, he referred the
patient to a pain clinic, and the patient
responded to the physician that if the physi-cian
did not continue to maintain his pre-scribing
for the patient, the patient would
burn the physician’s house down. This is
an extreme example of a drug-seeking
patient who is engaging in criminal behav-ior
and, in the process, is pressuring pre-scribing
physicians and dispensing pharma-cists
to aid in the criminal behavior. This is
a concept that is often referred to by feder-al
authorities as concurrent liability: pre-scribing
physicians and pharmacists can be
considered engaging in illegal activity for
participating in obvious criminal behavior,
the diversion of controlled substances. The
message from this session was that, while continued on page 5
we have focused a lot of necessary attention
on the importance of managing chronic
non-malignant pain, we must also consider
helping those practitioners who daily face
the dilemma presented by drug-seeking
patients – avoiding any involvement in ille-gal
diversionary schemes.
Views on Discipline
Yet another message comes from our crit-ics,
who at times seem abundant. Medical
boards are either doing too much or too lit-tle
in terms of disciplinary orders. Of
course, there is far more criticism in the lat-ter
category.
This Board receives over 600 com-plaints
from patients each year. Most of
these are triggered by poor communica-tion,
which may or may not be coupled
with poor outcome or unprofessional
behavior. Most everyone who complains
expects a disciplinary action in response.
Then there is the licensee. He or she reads
the last four or five pages of the Forum and
regularly sees what peers are sanctioned for.
At times, it appears all you have to do is
have a bad day at the office and you are
branded for the rest of your career. This
fear is exacerbated when read-ing
the summary narrative
behind the reported actions.
Licensee feedback suggests that
what sometimes appear to be
relatively minor incidents result
in public discipline. From the
Board’s perspective, minor
incidents don’t result in public
disciplinary action. There is
full due process afforded by law
before any public disciplinary
action is taken, and the events
leading to such action have to
be supported by a preponderance of the
evidence. No one gets a public disciplinary
action without opportunity for a hearing
unless there is imminent risk to the public
health, safety, and welfare that requires
emergency action. In those few cases
requiring emergency action, a licensee has
an opportunity for an expedited hearing.
The due process mechanisms available to a
licensee are perhaps not apparent to those
licensees who read the list of actions in this
publication, and a licensee may be left with
the impression he or she could end up on
these pages simply for being the target of a
vitriolic patient.
These divergent reactions from consumer
groups and complainants on one side and
licensees on the other are constant for most
medical boards. A simplistic view (mine) is
that medical boards function on a continu-
“There is feed-back
about a
real life situa-tion
that
plagues these
practitioners:
professional
drug-seeking
patients”
“No one gets a
public disciplinary
action without
opportunity for a
hearing unless
there is imminent
risk to the public
health, safety, and
welfare that
requires emergency
action”
No. 3 2000 5
Where should a medical board be on this
continuum? Perhaps it belongs somewhere
in between, tilting in favor of the con-sumers
that medical licensing laws were
designed to protect while providing full
due process afforded by law to licensees.
That means some bad outcomes and con-sumer
complaints will go unpunished.
Meanwhile, critics on either end of the con-tinuum
will not be happy. Most medical
boards get negative feedback from those
who advocate more extreme ends of
the continuum. This feedback is impor-tant
to our Board, even though it is almost
always negative. Feedback tells us we need
to work both sides of the argument.
We must be responsive to concerns
of consumers about
public protection
and to concerns of
licensees and their
lawyers that we act
within the law and
afford full due
process protections
of the law. An
argument can be
made that if a med-ical
board is being
criticized from both extremes, it is probably
moving in the right direction in terms of
protecting the public. People on both sides
of the issue need to know what this Board
is doing to protect their interests, and we
make every effort to let them know.
Conclusion
These are but a few examples of this
Board’s sensitivity to feedback. The Board
members and staff are readily available to
meet with any group to explore these and
other issues. We routinely meet with med-ical
society groups, hospital staffs, medical
students, deans of the medical schools, civic
groups, legal groups, and associates in other
states for this purpose. The Board’s current
president, Mr Wayne VonSeggen, has
appeared before a dozen or more groups
during his presidential year. Its upcoming
president, Dr Elizabeth Kanof, is already
planning a special group of presentations
across the state. This represents part of our
continuing effort to solicit your input and
feedback. You can give us your comments
by e-mail (info@ncmedboard.org), by fax
(919.326-1130), by post (PO Box 20007,
Raleigh, NC 27619), or by telephone
(919.326-1100/800.253-9653), as you
deem appropriate. If you would like a rep-resentative
of the Board (Board members
and/or staff) to address your group or orga-nization,
please let us know and we will do
our very best to accommodate you.
Feedback
continued from page 4
“An argument
can be made
that if a medical
board is being
criticized from
both extremes, it
is probably mov-ing
in the right
direction”
um. At one end, the board clearly doesn’t
do its job. Licensees who are outliers are
100% happy – no one gets disciplined.
(Notice that I qualified the licensee
response. I think the majority of good and
diligent physicians would be unhappy
because the outliers would represent a sig-nificant
blight on their profession. This
would have a negative impact on them and
the medical community. For the sake of
simplicity in outlining the continuum con-cept,
we will leave this majority of licensees
out.) At the same time, consumers are
unhappy. No one is protecting them from
outliers in the licensee population. At the
other end of this continuum, the board is
draconian – it imposes discipline as a result
of almost all complaints; thus most of the
complainants are happy. Licensees are
unhappy – they do not have due process
protection. Every time a complaint comes
in, a physician is sued, or there is a bad
medical outcome, someone is disciplined.
The board is fully responsive to its con-sumer
critics. Consumers don’t complain
about the board, but licensees do. The
board works on the assumption that a com-plaint
must have merit or a bad outcome
must be punished. On this end of the con-tinuum,
there is a true sense of urgency.
The magnitude of the consequences of
medical error are staggering. A summary
of the Institute of Medicine report en-titled
To Err Is Human: Building a Safer
Health System (which may be found at
http://books.nap.edu/catalog/9728.html) finds
that “... as many as 98,000 people die in
any given year from medical errors that
occur in hospitals. That’s more than die
from motor vehicle accidents, breast cancer,
or AIDS – three causes that receive far
more public attention. Indeed, more peo-ple
die annually from medication errors
than from workplace injuries. Add the
financial cost to the human tragedy, and
medical error easily rises to the top ranks of
urgent, widespread public problems.”
Some consumer watchdog agencies tell us
that medical boards should be taking many
more disciplinary actions – in effect, we
need a substantial phase shift on the con-tinuum.
This may be true, but there are
some with unrealistic expectations. An
extreme view, one taken at the polar end of
the continuum, is that malpractice equates
with incompetence and medical error
should necessarily be met with a punitive
response. (By the way, a medical board
could only function on this end of the con-tinuum
in another country, because there
would be no due process for the licensee.)
NCMB Announces
Hiring New Medical
Coordinator:
Gary M. Townsend,
MD, JD
Andrew W. Watry, executive director of the
North Carolina Medical Board, has
announced that Gary M. Townsend, MD, JD,
a native of Virginia, has been selected to
replace Jesse Earle Roberts, Jr, MD, as the
Board’s medical coordinator. Dr Roberts left
the medical coordinator’s position in March
2000 after almost three years of service.
Following his graduation from Duke
University in 1972, Dr Townsend received his
MD degree from West Virginia University in
1976. He obtained his JD from George
Washington University in 1980. He has been
licensed to practice medicine in North
Carolina since 1979 and is also licensed in
Maryland, Pennsylvania, Virginia, and West
Virginia. He is a member of the bar in
Pennsylvania and West Virginia.
Dr Townsend has practiced emergency
medicine since 1978 in Pennsylvania and
Maryland, and most recently at Dorchester
General Hospital in Cambridge, Maryland.
He has also practiced as a medical-legal con-sultant,
first on active duty with the U.S. Air
Force from 1986 to 1992, and, from then
until the present, as a civilian with the
Consultation Case Review Branch of the
Office of the Surgeon General, U.S. Army
Quality Management Directorate, located at
Walter Reed Army Medical Center in
Washington, DC.
A flight surgeon with the 167th Airlift
Wing of the West Virginia Air National
Guard since 1994 and commander of the
167th Medical Squadron since 1997, Dr
Townsend holds the rank of colonel.
His duties with the Consultation Case
Review Branch were quite similar to the tasks
he will undertake for the Board. The medical
consultant’s role is to assist and advise the
Board and the staff in areas requiring general
medical expertise and in the screening and
evaluation of complaints involving medical
care issues.
“We are delighted to welcome Dr
Townsend to the Board’s staff,” Mr Watry
said, “and are pleased with the experience and
expertise he brings to the position of medical
coordinator. Over the past three years, our
case review systems have improved remark-ably
thanks to the efforts of our outstanding
Complaints Department staff and to the hard
work and dedication of our first medical coor-dinator,
Dr Roberts. Dr Townsend is well
equipped to continue in that tradition and
add to it in meaningful ways. We look for-ward
to working with him.”
6 NCMB Forum
Abused men, too, are just as concerned for
their children and want the family unit to
remain in tact. Moreover, since women still
get physical custody
of children in over
85% of all divorce
cases, many men are
hesitant to leave, real-izing
that if they do
the courts may
severely limit their
access to their chil-dren.
For men, deciding to leave an abusive rela-tionship
is only half the battle. The other
half is: where do they go, who will believe
them? It seems that, in reality, barriers to a
male victim of domestic abuse are very much
the same as those facing a female victim just
a few short years ago.
Conclusion
Resources and facilities to combat domes-tic
violence are out there, but, unfortunately,
are still in short supply. Perhaps some bat-tered
women’s groups fear that if society rec-ognizes
that men are victims too, what little
money that is available will be diverted.
Continuing to portray partner violence
solely as a women’s issue is wrong, it is
counterproductive. No one has a monopoly
on pain and suffering. Until society recog-nizes
all the victims of domestic violence, we
will never be able to solve the problem.
Domestic violence is neither a male nor a
female issue – it is a human issue.
“Continuing to
portray partner
violence solely as
a women’s issue
is wrong, it is
counterproduc-tive”
Domestic Violence: Part 2
Battered Men: Another Story
Laura A. Queen
Outreach Coordinator, Women’s Aid In Crisis, Upshur County, WV
Billboards and radio and television ads
across the country proclaim that every few
seconds a woman is beaten by a man.
Violence against women is clearly a problem
of national importance. The United States
Department of Justice estimates that 95% of
reported assaults on spouses or ex-spouses
are committed by men against women. In
the three years I have been a domestic vio-lence
victim advocate in this county, I have
provided services to 450 clients, 10 of whom
were males.
Why the Silence?
While the very idea of men being abused
by their partners runs contrary to many of
our deeply ingrained beliefs about men and
women, female violence against men is a
phenomenon almost completely ignored by
the media and society.
Violence takes on many forms. There is
no question that since men are, on average,
bigger and stronger than women, they can
do more damage in a physical assault.
However, not all men are bigger than their
female partners and not all abuse is physical,
a fact that is pointed out over and over when
describing domestic violence.
And what of female-on-male violence?
Why don’t we hear about it more often? For
several reasons. First,
men in general are
extremely reluctant to
report that they have
been the victims of
any assault. After all,
men are supposed to
be tough, able to take
care of themselves,
right? What would
people think. . . ? Men are trained to solve
their own problems, not to ask for help.
Second, confessing to being knocked around
by another man is a piece of cake compared
to admitting being abused by a woman.
Why? Most likely, men fear, rightly so, soci-ety’s
traditional reaction. In France in the
eighteenth and nineteenth centuries, a hus-band
who had been pushed around by his
wife would be forced by the community to
wear women’s clothing and to ride through
the village sitting backwards on a donkey,
holding its tail.
The Female Potential for Violence
There are several serious effects of soci-
“Female vio-lence
against
men is a phe-nomenon
almost com-pletely
ignored
by the media
and society”
ety’s reluctance to acknowledge the female
potential for violence. First, women are sub-tly
encouraged to be more violent, eg, moth-ers
tell their daughters: “If he gets fresh,
slap him.” Second, while it is possible to
argue that a slap is unlikely to do any severe
damage, not recognizing that a slap is still
violence sets a dangerous precedent.
Arresting a man who slaps a woman, while
dismissing a woman’s slapping of a man as
nothing to worry about, both condones vio-lence
and reinforces a double standard that
historically has been used to oppress women
in the name of protection.
Men’s victimization cannot be denied,
however a few questions still remain. First,
if men are so much bigger and stronger, why
don’t they protect them-selves?
The answer
makes perfect sense. At
the same time little girls
are being told it is okay
to slap, little boys are
being told, “Never hit a
girl.” And when these
little boys grow up, they
are told that any man who hits a woman is a
bully. But if a woman hits him, he is sup-posed
to “take it like a man.” Also, many
men recognize the severe damage they are
capable of doing and, therefore, consciously
try to limit it. One male client I worked
with stated that his partner used the knowl-edge
that he would not strike back and con-tinued
the abuse. Another, after years of
physical abuse at the hands of his wife,
struck her in the face after she assaulted him.
She called the police, who, upon arrival,
arrested him for domestic battery, not believ-ing
his story that she struck first.
Leaving the Relationship
Not fighting back is one thing, but why
would any sane person stay in an abusive
relationship? I have learned in advocating
for men as victims that their reasons differ
little from women’s.
Economics plays a part. As more women
enter the work force, it is getting harder and
harder to find a traditional “man-as-the-sole-breadwinner”
family. Men are becoming
more dependent on their partners’ incomes
for family survival.
Many women fear that if they leave their
husbands, the violence they have experi-enced
may be directed against their children.
“Why would
any sane
person stay
in an abu-sive
relation-ship?”
About the Author
Ms Queen is the author of the article on
domestic violence that appeared in the previ-ous
number of the Forum. She is a talented
West Virginia artisan who, along with her
husband, handcrafts unique and beautiful
kitchen utensils from native woods: maple,
cherry, walnut, and hickory. Much of her
time is spent in the frontline fight against
spouse and child abuse. She has helped res-cue
hundreds of women and children from
all types of abuse, assisting them in putting
their lives back together. As this article
makes clear, she is also no stranger to the
abuse of men by their female partners. Her
voice has the ring of truth tempered by expe-rience
and she can tell stories that will bring
tears to anyone’s eyes.
No. 3 2000 7
At its meeting in September, the North
Carolina Medical Board adopted the follow-ing
Position Statement on Office-Based
Surgery.
Office-Based Surgery
Office-based surgery is surgery* per-formed
outside a hospital or an outpatient
facility accredited by the North Carolina
Division of Facility Services. Although
surgery is not a perfect science in any setting,
office-based surgery is generally safe, effec-tive,
and efficient, provided proper measures
are taken in the process. It is the position of
the North Carolina Medical Board that the
physician is responsible for providing a safe
environment for office-based surgery.
The following general guidelines are rec-ommended
for office-based surgery.
Training:
Any procedures, whether done in an office
or a hospital, should be performed by
physicians operating within their area of
professional training. Appropriate train-ing
and continuing medical education
should be documented and that documen-tation
should be readily available to
patients and the North Carolina Medical
Board. Those who perform office-based
surgery must have plans, such as pre-arranged
hospital admission protocols, for
managing emergency complications.
Patient Selection:
Patients must be evaluated per procedure
to determine if the office is an appropriate
setting for the surgery.
Patient Evaluation:
Patients undergoing office surgery must
have an appropriately documented history
and physical examination, and any other
studies or consultations indicated.
Anesthesia:
When general anesthesia or sedation is
provided in the office setting, it must be
administered by those qualified to do so.
Anesthesia personnel should be familiar
with variations in technique based on the
specifics of the patient and the procedure,
particularly those requiring large volumes
of fluids or airway management. Patients
must be properly monitored before, dur-ing,
and after the procedure. Physicians
are referred to the protocols of the
American Society of Anesthesiologists**
for guidance. ACLS certification of anes-thesia
personnel is an important consider-ation.
Office Setting:
The office should be set up with patient
safety as a primary consideration. Safety
issues should include, but not be limited
to, accessibility, sterilization and cleaning
routines, storage of materials and supplies,
supply inventory, and emergency equip-ment.
Emergency Planning:
Planning should include, but not be limit-ed
to, emergency medicines, emergency
equipment, and transfer protocols.
Practitioners should be trained and capa-ble
of managing complications related to
the procedures they perform.
Follow-Up Care:
As with any surgical treatment or proce-dure,
follow-up care by the responsible
surgeon is requisite. Arrangements
should be made for follow-up care and for
treatment of problems or complications
outside normal office hours.
Quality Improvement:
Continuous quality improvement should
be a goal.
.........................
* Definition of surgery as adopted by
the NCMB, November 1998:
“Surgery, which involves the revision,
destruction, incision, or structural
alteration of human tissue performed
using a variety of methods and instru-ments,
is a discipline that includes the
operative and non-operative care of
individuals in need of such interven-tion,
and demands pre-operative
assessment, judgment, technical skills,
post-operative management, and fol-low
up.”
** “Guidelines for Office-Based Anes-thesia,”
“Guidelines for Ambulatory
Anesthesia and Surgery,” “Basic
Standards for Preanesthesia Care,”
“Standards in Basic Anesthetic
Monitoring,” “Standards for Post-anesthesia
Care,” “Guidelines for
Nonoperating Room Anesthetizing
Locations.” All available from the
American Society of Anesthesiolo-gists.
[Adopted September 2000]
NCMB Adopts Position Statement on
Office-Based Surgery
About five years ago, a group of members
from our professional organization, the
North Carolina Association of Medical Staff
Services (NCAMSS), met with Bryant D.
Paris, Jr, then executive director of the North
Carolina Medical Board (NCMB), and H.
Diane Meelheim, assistant executive director
of the NCMB, to discuss what information
would be helpful to the medical staff profes-sional
if it were available on software. A sec-ond
meeting was held on April 3, 1998.
Three of us from the NCAMSS, Kay
Gibson, Deborah Chapman, and Donna
Masho, attended the meeting. Attending
from the NCMB were its then new execu-tive
director, Andrew W. Watry, Ms
Meelheim, and Rebecca Manning. The pur-pose
of the second meeting was to discuss
the software of the NCMB’s DataLink sys-tem,
problems encountered in medical staff
offices, and the benefits derived from having
access to practitioner licensing information
on a continuing basis.
Problems and Solutions
The main point of our discussion at the
April 3 meeting was the new state guideline
for license renewal dates (annually, on the
practitioner’s birthday). It has had an
impact on the medical staff office because of
a 60-day period that the license may be in
limbo due to the wording of the statute. It
was the consensus of the group that there
was not much we could do about the way
the statute is worded, but that we could
work toward establishing a process that
would be acceptable to the NCMB, hospi-tals,
and licensing and accrediting agencies.
A medical staff professional’s worst night-mare
would be finding an unlicensed physi-cian
on the staff of his or her hospital.
Those of us from NCAMSS found Diane,
Rebecca, and Andrew to be very aware and
concerned about our problems, with a real
willingness to help correct them. Several
ideas were discussed. We all agreed that the
more we can do through the software pro-gram,
the better it would be for everyone.
For example, added to the program was to
be a tickler file informing us of the date on
which the Board sent the letter of renewal to
the physician, who has 30 days to respond.
Using the NCMB’s
DataLink Software
Donna Masho, CMSC
Alamance Regional Medical Center
Kay Gibson, CMSC
High Point Regional Health System
continued on page 12
8 NCMB Forum
Prescriptions: Legal and Legible
Donald R. Pittman, Field Supervisor
NCMB Investigative Department
A pad of prescription blanks is found in
every physician’s office from Murphy to
Manteo, and as long as one is readily avail-able
to the physician, who gives it a second
thought? Please read on, you may learn that
many have and are giving the physician’s
prescription blank a second thought!
Pharmacists, nurses, patients, and regulatory
board investigators have all raised questions
about the pre-printed information and the
handwriting on the physician’s prescription
blank.
Pre-Printed Information
According to CFR (Code of Federal
Regulations) 1306.05, all prescriptions for
controlled substances shall be dated as of, and
signed on, the day when issued and shall bear
the full name and address of the patient, the
drug name, strength, dosage form, quantity pre-scribed,
directions for use and the name, address,
and registration (DEA) number of the practi-tioner.
The prescription may be prepared by
the secretary or agent for the signature of a
practitioner, but the prescribing practitioner
is responsible in case the prescription does
not conform in all essential respects to the
law and regulations. A corresponding liabil-ity
rests upon the pharmacist who fills a pre-scription
not prepared in the form pre-scribed
by these regulations.
NC General Statute 106-134.1(a) (4) a,
reads, “. . . written prescription must bear
the printed or stamped name, address,
telephone number, and DEA number of
the practitioner in addition to
his legal signature.” This NC
statute requires the referenced
information be on a prescription
blank whether the prescribed
drug is a controlled substance or
non-controlled substance (leg-end
drug). However, if you are
a physician, physician’s assistant,
or nurse practitioner who does
not have a DEA registration
number, then you are not per-mitted
to prescribe controlled substance
medications, only legend drugs, and, obvi-ously,
you are not required to put a DEA
number on your prescription blanks.
In addition to the federal and state regula-tions
noted above, nurse practitioners are
required by North Carolina Medical Board
rules to record the prescribing number
assigned to them by the medical board and
the name of their supervising physician(s)
on each prescription blank. Physician assis-tants
are required by similar Medical Board
rules to record their license number and the
responsible supervising physician’s (primary
or back-up) name and telephone
number.
Having sited these CFR and NC
General Statute/Rule references,
you may ask what all this means.
First, every prescription blank must
contain simple, basic information:
name, address, telephone number,
and DEA number of the prescrib-ing
physician or physician extender.
It is this basic information, either
missing or in error, that is causing
many to have second thoughts and questions
about physicians’ prescription blanks.
Handwriting
When you couple that lack of required
information on a prescription blank with the
serious and not uncommon problem of
scrawled and even indecipherable physician
handwriting, you have created extra work
for the dispensing pharmacist, who may
have to delay delivery of medication(s) to a
patient. The pharmacist cannot dispense
medication to a patient until he or she has
confirmed who the prescribing physician is
and/or what medication/dosage was intend-ed
to be dispensed. Whatever the source of
the pharmacist’s dilemma, it is one fraught
with the potential for error.
Pharmacists have called the Board’s office
to report they were unable to fill
a specific prescription because
they could not read the physi-cian’s
signature and the pre-scription
blank did not have the
physician’s name pre-printed on
it.
Two examples of prescription
blanks not having physicians’
names pre-printed on them are
those found in hospital emer-gency
rooms or county health
departments. When the pharmacist receives
such a prescription and the physician’s signa-ture
is no more than a squiggly line, he or
she must make an attempt to call the clin-ic/
hospital to find out who wrote the pre-scription.
Depending on the day and time
of the pharmacist’s call, it may prove impos-sible
to speak with the physician who wrote
the prescription. In fact, the pharmacist’s
call may not be answered at all, particularly
if the patient brings the prescription to the
pharmacy after the clinic has closed for the
day. If unable to confirm who authorized
the prescription, the pharmacist may be left
with only one option: tell the
patient to return the next day
after the pharmacist has had an
opportunity to speak with the
physician. Such delay is an
inconvenience to patients and
may be harmful to them.
A more serious problem
exists if the pharmacist is left to
decipher the drug name,
strength, quantity, and direction
for use when these are handwrit-ten
by the physician in an indecipherable
scrawl. The Institute of Medicine reported
last year that a range of medical errors,
including written miscommunication
between physicians and other health care
professionals, may claim as many as 98,000
lives a year. It has been suggested that doc-tors’
handwriting can be a contributing fac-tor.
Lawsuits have been filed and successfully
litigated regarding injury and death due to
illegible handwriting. In late 1999, a Texas
jury heard a case concerning the accidental
death of a 42 year-old man who suffered a
heart attack after receiving the wrong med-ication.
The physician intended the patient
to be given Isordil, 80mgs per day for heart
pain; instead, the pharmacist misread the
doctor’s handwriting and dispensed Plendil,
80mgs per day, a drug to treat high blood
pressure. Maximum recommended daily
dose of that drug is 10mgs. The victim’s
family was awarded several hundred thou-sand
dollars.
Conclusion
So, if you want to avoid getting telephone
calls at all hours of the day and night from
pharmacists stumped by your handwritten
prescriptions, and, even more bothersome, if
you want to avoid that hard bench at the
courthouse courtesy of litigation, include all
the required pre-printed information on
your prescription blanks and be sure others
can read and decipher your handwriting.
When pharmacists do call to inquire about
patients’ prescriptions, please answer their
questions in a professional manner.
Maintaining open communication and rap-port
is the best medicine for the patient.
“Lawsuits have
been filed and
successfully liti-gated
regard-ing
injury and
death due to
illegible hand-writing”
“Pharmacists have
called the Board’s
office to report they
were unable to fill
a specific prescrip-tion
because they
could not read the
physician’s signa-ture”
No. 3 2000 9
Mr Work
Prescriptions and New Technologies
Various new methods of transmitting pre-scriptions
have generated questions from
physicians and other prescribers. Systems
now exist for generating prescriptions
through a word processor or computer and
this is just one example of new technology
begetting more questions. Pharmacy Board
rules provide for electronic (.1814) and fax
(.1807) transmission of prescriptions, with
several specific requirements.
Perhaps the most significant technology
limitation on prescribing pertains to con-trolled
substances. Federal regulations gen-erally
prohibit the fax transmission of pre-scriptions
for Schedule II drugs such as mor-phine
or Dilaudid®, except for specific situ-ations
such as hospice patients or patients in
long-term care facilities.
At the state level, the responsible state
agency with jurisdiction over controlled sub-stances
is the Controlled Substances Drug
Regulatory Branch of the Division of Mental
Health, Developmental Disabilities and
Substance Abuse Services. It is their posi-tion
that prescriptions for controlled sub-stances
can be individually generated by a
computer and would be legal provided the
prescriber manually signs the document.
It is worth noting that only 10 to 15 per-cent
of prescriptions are for controlled sub-stances,
so the great bulk of prescriber’s
orders are easily transmitted either by fax or
electronically in the same way as e-mail. By
way of comment, the Pharmacy Board staff
recommends fax transmission rather than
telephone orders on both new prescriptions
and refill authorizations for several good rea-sons.
One is that there is a written record of
what was prescribed or authorized, which
promotes accountability. Another reason is
that pronunciation issues (Xanax® vs
Zantac®) are avoided and the
time/date/source tagline can verify validity.
From the North Carolina Board of Pharmacy
Focus on Prescriptions
David R. Work, Executive Director, North Carolina Board of Pharmacy
Although bogus prescriptions can occur in
any system, we have seen many more forg-eries
with phony telephone orders or stolen
prescription pads. This is a good reminder
for prescribers to keep closer track of their
unused prescription documents.
The status of a particular drug can be
determined in two ways. First, and easiest,
is to make a list of the drugs commonly used
in your practice and ask your local pharma-cist
which can be ordered electronically or by
telephone or fax and which must be ordered
in writing. Or each drug can be found in a
standard reference such as Facts and
Comparisons or The American Drug Index,
both available from their publisher at
800.223-0554. The Physician’s Desk
Reference is useless for this task because it is
an incomplete reference of some, but not all,
brand name drugs, and generics are not
included.
Drug Substitution
Physicians who are concerned about drug
substitution need to be aware of the func-tioning
of the state’s Product Selection (sub-stitution)
Law. The current statute allows
the substitution of a generically equivalent
drug for brand name drugs unless the pre-scriber
overrides the pharmacist in one of
several ways. The first method is by using a
two line prescription form that is prescribed
by statute (one line with “Dispense As
Written” on the lower right-hand side of the
prescription and one line with “Product
Selection Permitted” on the lower left-hand
side). Another is to write the words
“Dispense As Written” or “DAW” on the
face of the prescription. If the prescription
document is in another format, such as a one
line form, or if the prescriber fails to write
“DAW” on the face of the prescription, then
the pharmacist is able to use the generic ver-sion
of the drug.
NTI Drugs
The Product Selection Law also incorpo-rates
the Narrow Therapeutic Index (NTI)
concept into state law. This specific part of
the statute states that drugs that require
blood monitoring, or have formulation-dependent
variability, or whose toxic dose is
less than twice the effective dose must be
refilled with the same manufacturer’s prod-uct
used on the prior filling. If the pharma-cist,
or health plan, wants to change to a dif-ferent
manufacturer, then the pharmacist
must get the documented consent of both
the prescriber and the patient prior to
switching products. Drugs currently on the
NTI list are listed below.
carbamazepine (all dosage forms)
[Tegretol®, various others]
cyclosporine (all oral dosage forms)
digoxin (all dosage forms) [Lanoxin®]
ethosuximide (all oral dosage forms)
levothyroxine sodium tablets
[Levothroid®, Levoxyl®, Synthroid®,
various others]
lithium (all oral dosage forms, all salts)
[Cibalith®]
phenytoin (all oral dosage forms, all
salts) [Dilantin®]
procainamide hydrochloride (all oral
dosage forms)
theophylline (all oral dosage forms, all
salts) [Elixophyllin®, Slo-Phyllin®, Slo-
Bid Gyrocaps®, Theochron®, Theo-
Dur®, Theo-24®, Uniphyl®]
warfarin sodium tablets [BMS
Warfarin®, Coumadin®, Warfarin®]
Printed Forms
For many years, state statute has required
that all written prescriptions must bear the
printed name, address, telephone number,
and DEA number of the prescriber. This
exists primarily for a public health reason,
which is to provide pharmacists with a name
and telephone number to contact in case
questions about the prescription arise. The
most significant instance when this does
happen is when someone goes to a teaching
medical center for diagnosis and then brings
prescriptions back to his or her home com-munity.
It is not unusual for the documents
to be clearly written until the prescriber’s
name appears at the bottom with a scribble
or a swoosh that doesn’t give the pharmacist
any reliable reference in case questions exist
about dosage or potential drug interactions.
The presence of a printed name and tele-phone
number makes it possible for the
pharmacist to resolve any questions that
might arise.
Conclusion
If you have any questions about these or
other pharmaceutical matters that might
involve the Board of Pharmacy, we suggest
you review the Board’s Web page at
www.ncbop.org, scrolling to Frequently Asked
continued on page 10
10 NCMB Forum
Treating Bias
Researchers have no evidence that
American physicians withhold medical care
from minority and poor patients out of some
type of bias. But there is no end of evidence
that minorities and the poor routinely
receive inferior care, with the obvious result
of shortened lives or chronic illnesses that
mar their quality of life. That is intolerable.
The latest report pointing to racial and
socioeconomic disparities in medical treat-ment
comes from close by. Dr Kevin
Schulman, a Duke University internist, co-authored
a study that found a pattern in
which hospitals sometimes fail to recom-mend
simple, inexpensive therapies such as
aspirin to poor or African-American heart
attack victims upon their discharge from
hospitals. The study, which involved nearly
170,000 Medicare patients, was recently
published in a medical journal.
The gap in quality of care wasn’t as wide
as a chasm. But it was marked, and in real
numbers affects thousands of people. Other
studies also have shown that the poor,
Hispanics and blacks of all income levels
tend to be treated differently than their
white or more affluent counterparts for the
same illnesses.
Schulman thinks the way hospitals work,
especially ones with high loads of poor
patients, is to blame. If that is so, hospitals
could fix some shortcomings by, for exam-ple,
handing out written instructions to
patients who suffer from the same malady.
Still, Congress (or the states) needs to pass
legislation, already introduced in the U.S.
House and Senate, that would require med-ical
students to be trained about cultural dif-ferences.
Bias, whether knowing or inadver-tent,
has no place within the healing art.
__________
Editorial reprinted with permission from The
News & Observer of Raleigh, North Carolina,
8/15/2000. continued on page 11
Focus on Prescriptions
continued from page 9
Questions or New Developments. There is
also a section on Drug Law that some may
find interesting. Another good source of
information is the USP and their Web site at
www.usp.org. They have a program involving
medication error reporting and prevention
that has several specific recommendations,
including the electronic transmission of pre-scriptions
in lieu of handwritten documents.
On their Web site, click on Practitioner
Reporting, the National Coordinating
Council on Medication Error Reporting and
Prevention (NCCMERP), and then
Council Recommendations.
A Brief Guide to Continuing Medical
Education Requirements for Physicians
in North Carolina
A continuing medical education (CME)
rule for physician licensees of the North
Carolina Medical Board became official in
July 2000. Adoption of the rule was the
result of a legislative mandate that can be
found in NC General Statutes 90-14 (a)(15).
The rule itself appears at the end of this
Guide and may be found in the NC
Administrative Code at Title 21, Chapter 32,
North Carolina Medical Board, Subchapter
32R-Continuing Medical Education (CME)
Requirements.
When Does the Rule Become
Effective?
It becomes effective in 2001. You will
need to obtain and document for your files
the required practice-relevant CME starting
with your birthday on or after January 1,
2001. You will be asked to report your
total hours of applicable relevant CME
each year on your annual license registra-tion
form, but you will have three (3)
years to meet the requirement. Thus, the
first licensees required to have at least the
150 hour total (as defined in the rule) will be
those with birthdays in January who register
in 2004 and have been licensed for at least
three years. Others will have to meet the full
requirement by the month in which they
register in 2004 (if they have been licensed
for at least three years at that time).
Simply put, for a physician licensed
before January 1, 2001, the three-year
CME cycle begins on his or her birthday
in 2001. For a physician licensed during
or after 2001, the CME cycle begins on
his or her first birthday following the
granting of the license.(Some examples of
individual situations are provided below in
the section How Does the Three-Year Cycle
Work?)
How Can I Prepare for Reporting
and Documenting My CME?
We strongly recommend you set up a sys-tem
now for demonstrating compliance.
This will be easier than waiting until the last
minute and will help ensure the system is as
comfortable as possible for you in your cir-cumstances.
As you know, we have been
asking for CME reports on annual registra-tion
forms for some time, even though there
has not been a CME requirement in place for
physicians. Therefore, thinking about CME
reporting in the context of annual registra-tion
should be natural. You will find a CME
report segment on the registration form in
2001, as usual, with only some changes in
wording to remind you that CME is now
required and that you should maintain doc-umentation
of CME for six years. (And if
you hold licenses in other states requiring
CME, you should compare our requirement
with theirs to be sure your documentation
will be appropriate for each.)
Documentation for North Carolina
Credit 1 CME (provider-initiated) can be
as simple as keeping a dated record of your
attendance at or participation in relevant
CME programs conducted by ACCME or
AOA accredited institutions, along with a
file of receipts or certificates verifying the
information recorded. For North Carolina
Credit 2 CME (physician-initiated), it can
be as simple as keeping a list of relevant
CME activities initiated by yourself and not-ing
the nature of the activity, the date, and
the hours earned.
How Does the Three-Year Cycle
Work?
The Board’s new CME requirement is
based on a three-year cycle, a time period
similar to that used by a number of states
and medical organizations with CME
requirements or programs. However,
because the North Carolina system is keyed
to your birthday and because of the need to
report during your birth month as part of
our annual registration process, our system
will differ from some others. It may be use-ful
to give examples to demonstrate some of
the permutations. Below are some cases we
hope will clarify the process for those of you
who have questions about how the system
will work as reporting begins. Each example
assumes the hours mentioned represent rele-vant
CME and that the 150 hour minimum
includes at least the 60 hours of NC Credit
1 CME (provider-initiated) required by the
rule. Remember, the three-year CME
cycle will vary for each licensee depending
on his or her birth month and date of
licensing.
Physician A: Licensed in NC during 2000
or before, birthday in January. . .
The licensee must meet the 150
hour requirement by January registra-tion,
2004. Reports 0 hours in January
2001 (cycle opens, counting begins at
this point). Has several options. (1)
Can get 150 hours in March 2001,
report 150 hours at next registration in
January, 2002, report 0 hours in
January 2003 and 2004 respectively.
No. 3 2000 11
Brief Guide to Education
continued from page 10
That will meet the CME requirement as
of 2004. Then in 2004, the licensee
starts over, working for the 150 hour
total that will be needed by 2007. (2)
As an option, the licensee can get 150
hours in November 2003, reporting 0
in January 2002 and January 2003, and
reporting 150 in January 2004. (3)
Finally, the licensee can break it up,
reporting combinations such as 50
hours of CME in January 2002, January
2003, and January 2004. In any case,
the licensee starts with a clean slate in
January 2004, as the cycle starts over.
Physician B: Licensed in February 2001,
birthday in January. . .
Does not have to start counting and
reporting toward the 150 hours until
January registration, 2002. Does not
need to have all 150 hours until January
2005.
Physician C: Licensed in October 2002,
birthday in November. . .
Receives a registration form in
November 2002. Does not have to
report any CME on his November
2002 registration form, but has to start
counting and documenting CME
beginning in November 2002. Has to
have 150 hours by November 2005.
Physician D: February birthday, gets 150
hours of CME between February 1, 2001,
and February 1, 2002. . .
Meets the requirement early.
Reports the 150 hours on February
2002 registration, does not need to
report any CME in February 2003 or
2004. However, licensee is diligent
about CME and gets and reports 150
hours in 2003 and 2004 respectively.
Easily meets the requirement for 150
hours for registration in 2004: only had
to get 150 hours but reports 450 hours
cumulatively over the three years since
his registration in February 2001.
Cannot carry hours over to the next
cycle, however. Has to start with a
clean slate with registration in 2004 and
accumulate 150 new hours before
February 2007.
Physician F: Does not practice in North
Carolina but keeps license active, does not
set foot in NC during entire cycle. . .
Location does not matter, has to
meet requirement.
Physician G: Can only document 50 hours
at the end of 3 years, should have met
requirement. . .
Following full due process, includ-ing
notice and hearing, has exposure to
a public disciplinary order. The Board’s
action may or may not be considered by
another state as a bar to licensure, and it
may or may not affect hospital privi-leges
or eligibility for reimbursement by
Medicare or Medicaid. Whatever the
case, it is not worth it to the licensee.
Physician H: Has specialty board certifica-tion
with a board that has CME require-ments
that meet or exceed the requirements
of the NCMB; specialty board maintains
documentation. . .
The licensee’s CME must comply
with the NCMB rule in relation to cred-it
type, quantity, and time period, and
the licensee must report his or her CME
on the annual registration form. If the
licensee is one of those randomly select-ed
for inspection for CME compliance,
the documentation provided to the spe-cialty
board can be used but it must
meet the NCMB’s requirements. The
fact of certification itself is not docu-mentation.
Physician I: Has an inactive license, either
because he or she requested it or because of
failure to reregister. . .
Is not registered and, therefore, does
not have to comply with the CME
requirement unless or until license is
reactivated. (Those who hold inactive
licenses may not practice medicine in
North Carolina.)
How Does the Requirement Apply
to Residents in Training
The rule makes clear that licensees who
are residents enrolled in ACGME or AOA
accredited graduate medical education pro-grams
are exempt from the requirement.
What Is “Relevant” CME?
The idea of relevance is an essential part of
North Carolina’s CME requirement and sets
it apart from such requirements in many
other states. The CME used to satisfy the
North Carolina requirement, at either
credit level, must relate to your actual
practice of medicine. It seems obvious that
CME, to be meaningful, should be focused
on maintaining and enhancing your ability
to provide care for your patients or for those
patients affected by your professional ser-vices.
When asking yourself if the courses or
studies you want to pursue are relevant,
answer this simple question: Do they have a
direct impact on my care of my patients? If
you can make the case that the word and the
spirit of the requirement have been met,
there should be no problem.
Of course, some physicians do not treat
patients or provide professional services
related to the treatment of patients. Their
tasks are purely administrative or otherwise
have no direct effect on patients. CME for
them may be management related or institu-tional
in nature. However, if their work
involves review of medical records, signifi-cant
CME directed to patient care issues
would be called for. And if they see or pro-vide
professional services for patients on a
limited schedule, CME directed to their par-ticular
practice should be a significant part of
their CME effort. Again, they should be
able to make the case that the word and the
spirit of the CME requirement have been
met.
How Do I Compute My Various
CME Activities?
In the case of NC Credit 1 CME
(provider-initiated), ACCME and AOA
accredited institutions note the credit-hour
value of such programs in their printed
materials and announcements and on the
attendance/participation certificates they
give. Simply record these in keeping with
the number awarded by the institution.
NC Credit 2 CME (physician-initiat-ed)
presents a different situation. Some of
the twelve items listed do not fit a neat hour-by-
hour scheme, most do. Study, consulta-tions,
outcomes research, mentoring, teach-ing,
creation of generic patient care materi-als,
and participation in M&M conferences
and journal clubs can be measured by the
clock, though activities such as teaching
should include the time required for prepa-ration.
Competency assessment may involve
a variety of activities, all of which should be
included in the calculation of time. Passing
a specialty board examination can be count-ed
as the maximum three-year NC Credit 2
CME allowance. (Of the 150 hours of CME
credit required in three years, at least 60
must be NC Credit 1 CME. All the rest, up
to 90, may be NC Credit 2 CME.)
Can I Roll Excess CME Hours Over
to the Next Cycle?
No. The CME hours earned within a
three-year cycle can be used only to fulfill the
requirements for that cycle, which cannot be
extended or shortened.
Can I Use the PRA or Similar
Awards for Reporting?
Yes and no. You can use the records you
kept and reported to the AMA or other
organizations to earn their CME awards for
documentation, but you must highlight and
count only those CME experiences that
qualify as relevant, that meet the North
Carolina CME definitions, and that fit with-in
North Carolina’s three-year cycle.
Therefore, because of the need to demon-strate
relevance, to fit the CME defini-tions,
and to count only those hours
earned within your North Carolina three-year
cycle, the Physicians Recognition
Award and similar awards, taken by
continued on page 12
12 NCMB Forum
Brief Guide to Education
continued from page 11
themselves, cannot be accepted as docu-mentation.
How Will the Requirement Be
Enforced?
A random sample of registrants will be
asked to provide documentation of their
reported CME at the end of their reporting
cycles. Also, those who are called before the
Board for informal interviews or for formal
action will be asked to provide documenta-tion
of their reported CME. The Board
will take appropriate action against those
who fail to report completing the CME
requirement within a cycle and those who
cannot satisfactorily document their
CME reports. Board action will vary
depending on the particular circumstances.
What Do I Do If I Have More
Questions?
If you have a question not answered here,
e-mail us at info@ncmedboard.org. Or:
Fax: 919.326-1130.
Telephone: 919.326-1100.
Write: North Carolina Medical Board
Attention Registration, PO Box 20007
Raleigh, NC 27619.
CME RULE
Title 21 Chapter 32 North Carolina
Medical Board
Subchapter 32R - Continuing
Medical Education (CME)
Requirements
.0101 CONTINUING MEDICAL EDU-CATION
(CME) REQUIRED
(a) CME is defined as knowledge and
skills generally recognized and accepted by
the profession as within the basic medical
sciences, the discipline of clinical medicine,
and the provision of healthcare to the public.
CME should maintain, develop, or improve
the physician’s knowledge, skills, profession-al
performance and relationships which
physicians use to provide services for their
patients, their practice, the public, or the
profession.
(b) Each person licensed to practice med-icine
in the State of North Carolina shall
complete no less than 150 hours of practice
relevant CME every three years in order to
enhance current medical competence, per-formance
or patient care outcome. At least
60 hours shall be in the educational
provider-initiated category as defined in
Rule .0102 of this Subchapter. The remain-ing
hours, if any, shall be in the physician-initiated
category as defined in Rule .0102
of this Subchapter.
(c) The three year period described in
paragraph (b) above shall run from the
physician’s birthday beginning in the year
2001 or the first birthday following initial
licensure.
.0102 APPROVED CATEGORIES OF
CME
The following are the approved categories
of CME
(1) Educational Provider-Initiated CME:
All education offered by institutions
or organizations accredited by the
Accreditation Council on Contin-uing
Medical Education (ACCME)
and reciprocating organizations or
American Osteopathic Association
(AOA)
(a) Formal courses
(b) Scientific/clinical presenta-tions,
or publications;
(c) Enduring Material
(Audio-Video)
(d) Skill development
(2) Physician-Initiated CME:
(a) Practice based self-study
(b) Colleague Consultations
(c) Office-based outcomes
research
(d) Study initiated by
patient inquiries
(e) Study of community health
problems
(f) Successful Specialty Board
Exam for certification or recer-tification
(g) Teaching (professional,
patient/public health)
(h) Mentoring
(i) Morbidity and Mortality
(M&M) conference
(j) Journal clubs
(k) Creation of generic patient
care pathways and guidelines
(l) Competency Assessment
.0103 EXCEPTIONS
A licensee currently enrolled in an AOA or
Graduate Medical Education (ACGME)
accredited graduate medical education pro-gram
is exempt from the requirements of
Rule .0101 of this Section.
.0104 REPORTING
At the time of annual registration imme-diately
following the CME reporting period,
each Licensee shall report on the Board’s
annual registration form the number of
hours of practice-relevant CME obtained in
compliance with section .0101 of this
Subchapter. Records documenting CME
hours must be documented by categories for
six consecutive years and may be inspected
by the Board or its agents.
A special file was also to be added to the
Board Action Section of the program listing
all physicians whose licenses have been
declared “inactive.”
To all the staff members at the NCMB
who supported the initial concept of the
DataLink program, along with the hospitals
that have supported and purchased the soft-ware,
we, as medical staff professionals,
would like to say “thank you.” DataLink is
a very important part of the credentialing
process at most North Carolina hospitals. In
fact, it would be wonderful if, somehow, the
same licensing data, provided by their licens-ing
agencies, could be downloaded into
DataLink for the dentists, podiatrists, and
optometrists. Maybe this could be a joint
venture.
Hospitals Need DataLink
To those hospitals that do not have
DataLink, we would say that you are miss-ing
out on a great credentialing tool! As
more and more hospitals are linked to this
program, JCAHO surveyors will expect to
see the presence of this software during your
survey process. With the new regulations
for licensing, if your license information is
not computerized, you will have a creden-tialing
nightmare.
Area hospitals have found access to
DataLink to be very reliable and the staff
at the NCMB have
always responded in a
prompt and courteous
way. The DataLink is
considered a primary
source verification,
and JCAHO surveyors
have been impressed
with DataLink and the
fact that it offers 24-hour access, seven days
a week. DataLink is also good for verifying
licenses of non-staff physicians that order
non-invasive tests or labs or refer a patient to
one of your outpatient services.
NCAMSS would like to take this oppor-tunity
to say “thank you” to the staff of the
NCMB for their help in providing us with
DataLink, and for including members of our
association as participants in meetings to dis-cuss
updates of the software.
“DataLink is a
very important
part of the cre-dentialing
process at most
North Carolina
hospitals”
DataLink
continued from page 7
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina Medical Board
No. 3 2000 13
at 11:00 a.m. My mother explained that
the only other problem she could tell was
that he was “a little clammy.”
My father had not been to a doctor in
over 20 years. He is a heavy smoker, and
he is mildly overweight. Several possibil-ities
of what could be wrong crossed my
mind: cholelithiasis or cholecystitis,
appendicitis, pancreatitis, early bowel
obstruction, a GI virus, or kidney stones.
I just was not sure. I finally asked my
mother to go to the den, to have my
father lie down on the couch, and to get
on the phone in the den. When she got
back on the line, I explained to her how to
divide the abdomen into four quadrants,
with the belly button being the center
point. I told her to feel the upper right
side and push down gently. She did that,
and it did not cause any pain. Then she
moved down to the right lower area and
did the same. Again, this was not uncom-fortable.
She then went to the left lower
quadrant. This area was not tender either,
but as she moved her hand up she said,
“Charlie, what is this hard lump?” He
said he had not noticed anything there. I
asked the size and location, and she told
me that it was like a baseball to the left of
his belly button. She kept feeling it, and
then came the dreaded words: “Laurie, it
feels like it is thumping... like it has a
heartbeat.” My heart sank! I knew at this
point exactly what he had without a
doubt, a large abdominal aortic aneurysm
that was obviously leaking and causing the
pain in his back and abdomen. I tried to
remain calm so I would not scare my
mom, but I think she knew it was bad. I
told her to take him to the closest hospital
right away. I had her write on a piece of
paper “pulsatile abdominal mass, left of
umbilicus” and give it to whomever she
saw first when they got there. Because it
would be faster and my father was still
talking and able to move around, I told
her to drive him to the hospital rather
than call and wait for an ambulance.
When they arrived at the emergency
room, my mom handed the paper to the
nurse. From then on, things moved
incredibly fast. The CT, performed even
before registration, revealed a 9.2 cm leak-ing
abdominal aortic aneurysm. My
father asked to speak to my mother, and a
pastor came in to see him, because the sur-geon
gave a rather grim prognosis. He
was in the operating room within 30 min-utes.
He survived the operation, but he
required reintubation 2 days postopera-tively
and required a total 10 units of
blood. He was discharged 14 days post-operatively
and has recovered completely.
It is difficult to write about this even
now. I still get tearful when I think about
how close he came to dying. I was so
close to telling my mother that night to
just have him lie down for a while and see
if he felt better. But the fact that my dad
was complaining of pain, I knew it had to
be more than just a “flu.” My mother did
all the right things to help me determine
that it was worse than either of us could
have guessed. The pieces, for whatever
reason, fell together and allowed my dad
to pull through what is generally a fatal
situation. We are truly fortunate, and it
really is a miracle.
Others have documented the contribu-tions
of physician assistants with respect and
admiration. Miller et al* demonstrated that
physician assistants can be an excellent alter-native
for a trauma center that does not have
surgical residents. In a three-year study of
their trauma experience, these trauma sur-geons
reported that physician assistants
saved them 4 to 5 hours per day, reduced
patient transfer time from the emergency
department, and reduced lengths of stay.
Perhaps the best indicator of the value of
this new profession is the recent election of
Mr Wayne W. VonSeggen, a practicing
physician assistant for more than 20 years, to
the presidency of the North Carolina
Medical Board. This was not a political
process. Mr VonSeggen served as president
of the North Carolina Academy of Physician
Assistants from 1983 to 1984 and held posi-tions
on numerous other committees over
the years. Mr VonSeggen was chosen unan-imously
by a board that is two-thirds physi-cians
– physicians recognizing his adminis-trative
skill, his integrity, and his thoughtful
judgment.
In the reviews of the surgical advances of
the last millennium, we saw many citations
on cardiac surgery, transplantation, minimal-ly
invasive techniques, and breakthroughs in
monitoring. We would like to add another,
often overlooked topic, the development of
physician assistants and nurse practitioners.
We delight in their success and wish them
well for at least another century.
.........................
* Miller W, Riehl E, Napier M, Barber K,
Dabideen H. Use of physician assistant as
surgery/trauma house staff at an American
College of Surgeons-verified level II trauma cen-ter.
J Trauma 1998; 44:372-376.
_________________
Reprinted with permission from Current Surgery,
Vol. 57, No. 2, March/April 2000.
Surgeons rarely
practice alone. Folks
may think of us as
Lone Rangers, but
we do our best work
when we have a col-league
across the
table. I learned this
on my first day on
the clinical wards
when my older sis-ter,
an experienced
nurse, told me the
secret of survival, “Stay on the good side of
the nurses.”
The advice is still sound, but today, it
should be expanded to include a newer
group of professionals misnamed “physician
assistants.” They do more than assist; they
serve as our ears and eyes, our hands, and
often our consciences. They are true col-leagues,
and we are fortunate to have them
at our sides.
In surgery, we teach with stories. Let me,
therefore, share a story with you as told by
Ms Laurie Driscoll, an excellent physician
assistant working in our department here at
the Brody School of Medicine at East
Carolina University.
I had just walked in the door from
work, and the phone was ringing. It was
my mother. She called because my father
had been having vague abdominal and
lower back pain since about noon. It was
now 6:00 p.m., and he was not any better.
All of this was very unusual because my
father has never really been sick, and he
rarely complains about aches and pains.
Earlier that day, he had gone to his reg-ular
Wednesday morning card game in
Fort Pierce, a small town in Florida about
30 minutes from his home. He began
having vague, diffuse abdominal cramp-ing
around 1:30 p.m.. He played cards
until about 4:30 p.m. and then came
home. He explained to my mother the
pains he was experiencing, and my moth-er
gave him Gas-X. It provided no relief.
In addition to his abdominal pain, he also
began to have lower back pain, and he
complained of having to belch a lot.
After my mother had relayed the entire
story, I began asking her some routine
questions. “Was there any nausea or vom-iting?”
“None.” “Had he experienced any
diarrhea?” “No.” “Had he had a normal
bowel movement that morning?” “Yes.”
“Was there any pain or burning upon uri-nation?”
“No.” “Did he have an
appetite?” “None,” and he had last eaten
Dr Pories
The Physician Assistant
Walter J. Pories, MD, Secretary/Treasurer, NCMB
with Laurie Ann Driscoll, PA-C
14 NCMB Forum
LETTERS TO THE EDITOR
Legislation Is the Best
Solution to Records
Problem
To the Editor: Two articles in the Forum
recently struck an especially resonant chord,
due not only to their content but also their
physical proximity by appearing in the same
issue (Roufail, WM: HMOs: Have We
Painted Ourselves into a Corner? and Watry,
AW: Patient Access to Medical Records,
both in the Forum, 2000;Vol. V, No. 2).
While agreeing wholeheartedly with the for-mer,
the latter produced serious misgivings.
When decrying the death of traditional
private medical practice at the hands of “big
business,” HMOs, and the federal govern-ment,
Dr Roufail tellingly places the blame
for Mr Watry’s problem regarding patients’
decreased access to their medical records
exactly where it belongs: with the physi-cians,
patients, captains of business, voters,
and politicians who either built today’s mis-managed
care juggernaut, cheered it on, or
simply stood idly by while it grew to mono-lithic
proportions. Mr Watry’s concerns are
certainly well-founded, but some of his solu-tions
seem less than optimal considering the
climate in which most contemporary physi-cians
must work.
Mr Watry warns against legislation placing
a dollar value on medical records, yet here in
West Virginia the legislature’s appraisal,
years ago, of not more than $1.00/page for
copies of medical records solved many more
problems than it created. Interestingly, and
probably not coincidentally, this is the same
value the market had placed on copies of
legal documents, specifically copies of depo-sitions
in medical malpractice litigations.
Having a statutorily defined value makes
physicians’ patient records simply another
product in the medical business inventory,
another order to be filled and shipped,
another source of cash-flow. Certainly, cus-tomers
are always entitled to purchase prod-ucts
through an open market at a profit to
the provider.
As far as his lament about loss of continu-ity
in patient care, Mr Watry surely recog-nizes
that it was literally thrown out with the
baby’s bathwater when medical care mega-corporations
began employing “independent
primary care providers” such as nurse practi-tioners
and midwives, physician assistants,
and “doc-in-the-box” physicians who were
rotated daily through a pool of storefront
clinics in widely-spread locations. Patients
moving down the high-efficiency, maximum
production assembly lines of these medical
care factories already, in Mr Watry’s words,
“are left in the lurch, not knowing who is
going to treat them next, who has access to
their records, and whether or not their
records are in a secure location; and they are
left without appropriate mechanisms for get-ting
these records to a new health care
provider in order to provide continuity of
care.” When he refers to the way things used
to be “[i]n days past,” that’s exactly what
they are: past, gone, over, history. We now
practice within a new paradigm.
Legislation is certainly the best alternative
solution to any problems with patient access
to medical records, realizing that statutory
relief ideally is intended to establish only a
minimum legal standard that should be fair
to all parties involved. Such legislation
should first of all relieve private physicians of
eternal responsibility for record maintenance
by defining a statute of limitations after
which, if there were no subsequent entries,
any records, financial or medical, could be
safely destroyed without fear of litigation or
prosecution.
Secondly, responsibility for medical
records should rest with the legally and con-tractually
defined custodian, not necessarily
the attending physician. This is already the
case with the records of hospitals and corpo-rate
care entities, so there’s no plausible
argument for maintaining this onus indefi-nitely
on private physicians who sell their
practices or retire, nor on their estates and
survivors when they die. The office records
are simply another asset purchased in the
deal or listed in the estate and should carry
no greater responsibility for their mainte-nance.
While legislation presents the imposition
of a minimum standard, it is obvious that
almost all physicians in private practice will
operate their businesses to a higher standard
out of respect for traditional medical ethics
and responsibilities. Lawyers, government
administrators, and insurance companies
should be charged the maximum allowable
by law for their requested records, yet
patient and collegial requests will almost
always be honored pro bono. I personally still
maintain all records, both financial and med-ical,
of every visit of every patient ever seen
in my private practice. Although sometimes
involving repeated requests and voluminous
documents, no patient has ever been directly
charged for copying and mailing her records.
Over the years, many colleagues in private
practice have either moved, retired, or died,
and almost all their patients have been noti-fied
by newspaper advertisements or direct
mail regarding where their records would be
transferred (usually another local physician’s
office) or a date until which records would
be transferred at no charge upon patient
request to a physician designated by the
patient, afterward allowing destruction of
untransferred originals.
While there is never an ideal solution to
any problem that will completely satisfy all
parties, patients who opt to continue their
care within the traditional private practice of
medicine will have fewer complaints and
these can be easily addressed through state
medical licensing boards and local medical
societies existing mechanisms. For the rest,
legislation already insures fair treatment to
all participants in various business transac-tions
by clearly defining rights and responsi-bilities
of each without imposing unreason-able
burdens upon any. It will do the same
in the medical marketplace.
William D. Daniel, MD, FACOG
Executive Director, American Society
of Forensic Obstetricians and
Gynecologists, Buckhannon, WV
Response
Thank you for your letter. We appreciate your
insight and commentary. I have this skepticism
(perhaps unfounded) that when issues like this
are brought to a legislative agenda there is expo-sure
to getting more than you bargained for.
For example, no one would reasonably argue
that our government should not have open
records and citizens should not have access to
them. I am aware of one state, however, that
mandates open records must be provided in three
working days. Thus, the response to an open
records request becomes a higher priority to the
agency than its other legislative mandate (med-ical
licensure) that has no time limits imposed
on how quickly someone is licensed or disciplined.
Your points provide balance to my argument
and I thank you for them.
Andrew W. Watry, Executive Director
North Carolina Medical Board
And More on
Medical Records
To the Editor: The article Patient Access to
Medical Records written by the Board’s
executive director, Andrew W. Watry, MPA,
continued on page 15
No. 3 2000 15
in No. 2, 2000, of the Forum, presents the
North Carolina Medical Board’s position
regarding charges for copying and postage
of patient records incorrectly.
Mr Watry states in his article: “Another sit-uation
we see with increasing regularity is
the physician holding records until payment
is made for an unsettled account or for the
copying of the records themselves. This is
contrary to the Board’s position statement
on medical records.” Mr Watry goes on to
say that “maintaining and keeping files is a
cost of doing business, . . . .”
The NCMB Position Statement, as
amended 9/1997, says, “The physician may
charge a reasonable fee for the preparation
and/or the photocopying of the materials.”
This clearly contradicts the notion that copy-ing
and mailing is free to the recipient or “a
cost of doing business” to the practice.
I support the policy given in the 1997
NCMB Position Statement. While there is
little room for debate that maintaining and
keeping files for the purpose of patient care
within the practice has long been universally
accepted as a cost of doing business, the
expense of copying, handling, and postage
of records for transfers has not been univer-sally
accepted. Furthermore, adding to the
long list of documents, forms, and records
that are furnished at “no additional charge”
is beyond the pale. Indeed, many services,
so considered in the past, may now need
reconsideration. Faced with the choice of
allocating scarce personnel and other
resources to the task of preparing and trans-ferring
2/3-year-old medical records or car-ing
for the patients at hand, I have little
doubt how healthcare providers should pri-oritize
tasks. If forced to do otherwise, I fear
the quality of care might be threatened. It
might make more sense to encourage physi-cians,
attorneys, insurance companies,
employers, and the myriad of others request-ing
“All Medical Records” to limit their
requests in both number and scope. Paying
their way would be a step in that direction.
After all, cost shifting is just about a thing of
the past!
G. David Dyer, MD
Wrightsville Beach, NC
Response
Thank you for your letter. The premise of your
argument seems to be that when I refer to
“maintaining and keeping files is a cost of doing
business. . .” I am suggesting that these copying
and mailing costs should be free to the recipient.
I respectfully disagree for two reasons.
Letters to the Editor
continued from page 14
(1) I am not aware of anyone in business who
assumes that a “cost of doing business” should be
free to a recipient. These costs are almost always
passed to customers in one form or another.
There is no free lunch.
(2) You terminated my quote at a place that
takes the sentence out of context. The whole sen-tence
was: “Maintaining and keeping files is a
cost of doing business, and it is recognized that
in many businesses it is acceptable to withhold
services until fees are paid. For the most part,
this is not so in medicine.” This is not advocacy
for furnishing records at no charge. There is a
big difference. I go on in the article to state
options, such as collection agencies. I am trying
to help physicians and their patients avoid a
major quicksand pit when medical records are
held for payment of a fee. Imagine a physician
defending himself or herself in a courtroom for
not sending a mammogram to an oncologist
because a fee had not been paid yet, compromis-ing
continuity of care. How do you think a jury
would rule?
Thank you for your comments. We are at your
service if we may assist you in any way.
Andrew W. Watry, Executive Director
North Carolina Medical Board
Male Victimization
To the Editor: Regarding the Special Topic:
Domestic Violence [by Laura A. Queen]
that you published in the Number 2, 2000,
issue of the Forum, I applaud your intent in
bringing this important issue to print, but I
must point out that the victims of domestic
violence are not always female. In fact, there
have been cases, though rarely reported, of
males/husbands who were victims of vio-lence
perpetrated by women in the house-hold/
wives.
Of all the printed material and conferences
on domestic violence, I have yet to see or
hear any mention of male victims. Though
almost never reported, male victims do exist.
And I think it would serve to generate more
feedback if every presentation on domestic
violence made mention of male victimiza-tion.
Thank you for disseminating this view-point.
Frank Y. Yang, MD, FACS
Pinehurst, NC
Response
We appreciate your comment and the
thoughtful view you bring forward. We hope you
will note Ms Queen’s second article, which
appears in this number of the Forum, titled
Battered Men: Another Story.
The Editor
Vital Information
Required
by the NCMB
When a physician or physi-cian
extender dies or legally changes
name by marriage, divorce, or other
legal means, that information is
vital to the North Carolina Medical
Board to ensure the accuracy and
completeness of its records and to
effectively serve the interests of its
licensees and the public. Copies of
the legal documents relating to
those events are also needed to add
to the appropriate files.
When a licensee dies, a copy
of the death certificate should be
sent to the Board as soon as possi-ble.
When a licensee marries and
thereby changes name, a copy of the
marriage certificate, showing the
name change, should be forwarded
to the Board. In the case of divorce,
if the decree contains the resump-tion
of a maiden or previous name,
copy of the decree should also be
sent to the Board. When a
licensee’s name is changed by any
other legal means, the relevant legal
document(s) should be sent to the
Board.
It is important to note that
without the legal documentation
the necessary changes cannot be
made to the Board’s records, and
that will result in incorrect names
on registration forms, incorrect ver-ifications
of license, and misinfor-mation
should a licensee be
deceased.
This vital information, and
the supporting copies of relevant
documents, should be sent to the
following address: North Carolina
Medical Board, Attention: Ms Ann
Norris, PO Box 20007, Raleigh,
NC 27619.
16 NCMB Forum
education at St Thomas’s Hospital, London,
Cream’s fiancee became ill and her father
discovered she was experiencing complica-tions
of a recently induced abortion per-formed
by person or persons unknown,
assumed to be Cream. A literal “shotgun
wedding” was quickly performed before
Cream’s embarkation, but less than a year
later the newly wed Mrs Cream died follow-ing
a short illness with suspicious symptoms
which were treated with pills mailed by her
husband from London.
During his studies at St Thomas’s, Cream
was exposed to Dr Albert James Bernays,
professor of chemistry and a medical expert
witness for the Crown Prosecutor in a high-profile
trial charging murder by strychnine
poisoning. The case had been difficult to
solve due to the lack of uniformity in British
coroner inquest law, the prestigious British
Medical Journal opining that as a result
many violent deaths by poisoning were
probably going uninvestigated.
Cream also took advanced training in
obstetrics at St. Thomas’s while Lister
sprayed carbolic acid around the operating
rooms at nearby General Lying-In Hospital,
but in 1877 the young Canadian obstetrician
failed his anatomy and physiology entrance
examinations for the Royal College of
Surgeons. The following year, he was
admitted to the Royal Colleges of Physicians
and Surgeons, Edinburgh, with a midwifery
license and in May returned to London,
Ontario, where he opened an obstetrical
practice. Following the death of a patient
from an overdose of chloroform suspected
to have been employed as an anesthetic for
elective abortion (her body was discovered
in the outhouse behind his office), Cream
hastily crossed the border to Chicago and
was licensed by the Illinois State Board of
Health in August 1879, promptly opening a
medical office in the city’s busy red light dis-trict.
Cream had long been known as a woman-izer
and frequent consort of prostitutes, and
it was common knowledge he provided
abortions. Another patient was discovered
dead and decomposing in a rooming house,
apparently following postabortal sepsis.
Arrested and charged with murder, Cream
was acquitted primarily due to the skill of his
defense attorney and the fact that the state’s
only witness was a “colored” lay midwife
who occasionally assisted him. After the
death of a third female patient under suspi-cious
circumstances, failed blackmail and
extortion schemes, a sordid libel attempt,
and the recent poisoning of his cuckold
patient noted above, Cream hurriedly left
Chicago and returned to Canada.
Within a month, he was arrested in Belle
Riviere, Ontario, taken to Windsor for ques-tioning,
and extradited to Chicago to stand
trial for the murder of his mistress’s hus-band.
He was again tried for murder, this
time convicted in September 1881 and sen-tenced
to life imprisonment in Joliet State
Prison with at least one day a year to be
spent in solitary confinement. Ten years
later, Illinois Governor Joseph W. Fifer
granted Cream executive clemency with
release in July 1891.
Returning to Canada and collecting a
modest inheritance, Cream then set sail
again for London where he took rooms
across the street from St. Thomas’s Hospital
but never again practiced medicine in the
traditional sense. He did represent himself
to acquaintances and potential victims as a
physician, even offering pills he compound-ed
himself for their various symptoms.
Cream quickly became a frequent customer
of the many prostitutes working nearby,
claiming multiple sexual encounters in an
evening, and was known to be obsessed with
pornography. He also became a regular user
of opium, morphia, cocaine, and beverage
alcohol to excess.
Following the deaths of two prostitutes
shortly after being seen with Cream, he once
more left town and sailed to Canada, but
returned to London after three months and
again took lodgings among its prostitutes in
the entertainment district. Two more of his
female acquaintances subsequently died of
arsenic poisoning. On 3 June 1892, he was
arrested by Scotland Yard on charges of
continued on page 17
REVIEW
“When a doctor goes wrong he is the first of
criminals. He has nerve and he has knowledge.”
Sir Arthur Conan Doyle
The Speckled Band, 1891
One of the earliest known serial killers was
Thomas Neill Cream, MD, hanged 15
November 1892 at age 42 years for the mur-der
(by surreptitiously giving them oral
arsenic represented as legitimate medication)
of four London prostitutes. Cream most
likely was responsible for the premeditated
murders by poisoning, either with arsenic or
chloroform, of at least five others in North
America, including his Canadian wife and
four of his U.S. patients, in addition to
untold London prostitutes. One of his
patients so dispatched was a paramour’s
elder husband and Cream intended to subse-quently
profit from an unsuccessful black-mail
scheme, threatening the victim’s phar-macist
with being revealed as the poisoner.
Cream was much more successful at murder
than extortion or blackmail.
Born 27 May 1850 in Glasgow, Scotland,
Cream emigrated with his family to
Montreal, Canada, in 1854, where his father
prospered in business and young Thomas
taught Sunday school. In March 1876, he
received, after four year’s study, the MD
degree from Quebec City’s McGill College,
presenting his graduation thesis on the phar-macological
properties of chloroform. The
occasion’s speaker addressed the graduates
on “The Evils of Malpractice in the Medical
Profession.”
Shortly after his graduation and prior to
sailing for England to continue his medical
Dr Harer
Doctor Death:
The Ultimately Impaired Physician
W. Benson Harer, Jr, MD, President
The American College of Obstetricians and Gynecologists
No. 3 2000 17
historian’s commitment to detail and
chronology. One shouldn’t be surprised, as
McLaren, professor of history at the
University of Victoria, Vancouver, British
Columbia, is an established author on schol-arly
topics both historical and social.
The second half is less like a yellowed,
dog-eared copy of an old Police Gazette or
New York Daily News, more interesting and
intellectually challenging as McLaren skill-fully
reweaves the fabric of life at the turn of
the century. That era’s women tried to con-trol
their fertility by using contraceptives or
seeking elective abortions, while various
moral and legal authorities simultaneously
tried to either aid or frustrate such efforts.
He describes law enforcement’s progression
from apprehension of criminals after the fact
to surveillance of potential perpetrators,
crime prevention, and, finally, actually pro-moting
crimes through enticement and
entrapment in order to make arrests. He
also explains how, during the late 1800s, rev-olutions
in cheap communication and trans-portation,
such as widely distributed period-icals,
reliable public mails, anonymous post
office box addresses, mimeographs, plus fast
steamships and trains, made both legitimate
and illegal activities more easily and effi-ciently
conducted. One hundred years later,
satellites, personal computers, the Internet,
and jet aviation have remarkably done the
same during the last 20 years of our century.
Suffragettes and other activists fighting
for the electoral, personal, legal, and proper-ty
rights of women, both married and single,
threatened an already unstable status quo.
Other studies of late 19th-century society
have focused on England, but Cream’s
exploits in Canada and the U.S. give us a dis-tinctly
American view of similar problems
for women on this side of the Atlantic.
Devout feminists will find much for justified
outrage here.
Our concepts of criminal behavior, moti-vation,
genesis, control, punishment, and
rehabilitation remain even today far from
providing effective preventatives. Dispari-ties
in legal and societal status of women
remain with us, as do prostitution and
exploitation. Women, especially prostitutes,
continue to be the prime victims of murder-ers,
rapists, assaulters, batterers, muggers,
and other violent criminals, with little pro-tection
except what they themselves provide.
Control of their sexuality and fertility
remains hotly and sometimes violently con-tested.
Serial murderers continue to own the
headlines on occasion. McLaren contends
that Cream and his crimes are best under-stood
as the products of an already sick Late
Victorian society and he won me over with
his arguments. Other readers may find alter-
Review
continued from page 16
nate explanations.
.........................
Reprinted with permission from The Medicolegal
OB/GYN Newsletter of The American Society of
Forensic Obstetricians and Gynecologists, PO
Box 536, Buckhannon, WV 26201-0536.
blackmail, on 18 July charged with murder
in the deaths of four prostitutes, during 17-
21 October tried by the Crown in Old Bailey
court rooms, on 21 October found guilty
after ten minutes’ deliberation by a jury of
his peers, immediately sentenced by the pre-siding
judge to be hanged by the neck until
dead and God’s mercy invoked on behalf of
his soul, and executed 15 November at
Newgate Prison.
–––––––––––––––––––––––––––
A Prescription for Murder: The Victorian
Serial Killings of Dr. Thomas Neill Cream
Angus McLaren
University of Chicago Press, Springer-
Verlag, Chicago, IL, 1993
233 pages (illustrated), $12.95 paperback
–––––––––––––––––––––––––––
In the finest police tradition, Scotland
Yard took full credit for the investigation and
arrest, yet McLaren clearly shows it was
Cream’s own hubris in calling attention to
the murders (first officially dismissed as sui-cides
or food poisonings), coupled with the
prostitute community’s coordinated and
persistent efforts to protect itself, that led to
his capture. McLaren has not written a
deep, psychological analysis of the serial
murderer’s criminal mind but instead an his-torical
and social analysis of moral, econom-ic,
and political conditions during the late
1800s which fostered or at least allowed
Cream’s professional failure, ever-deepening
descent into moral degradation, and eventu-ally
prolonged macabre crime spree.
The author examines quite well the role
society then demanded for women in gener-al,
prostitutes in particular, and the subse-quent
changes in its views of crime, law
enforcement, and the judicial system regard-ing
punishment of criminals and the status
of women. Since God dictated the Ten
Commandments to Moses, murder has been
recognized as the ultimate crime against per-sons,
with, over the last 150 years, serial
killers filling a special niche. Prostitutes have
always comprised a remarkably large num-ber
of their victims. Undoubtedly, society’s
attitudes toward commercialization of sex in
general and prostitutes in particular have
made their victimization much easier.
The first half of McLaren’s book, summa-rized
above, is a straightforward factual
account of Cream’s life, such as it was. It
avoids sensationalism, conjecture, and inter-pretation
as much as possible while holding
the reader’s attention with its well-written
Editor’s Note: The end of the 19th centu-ry
saw still another medical monster in the
person of Herman Webster Mudgett, who
renamed himself Harry Howard Holmes.
Born in Gilmanton, New Hampshire, in
1860, and trained at the University of
Michigan Medical School, he was to
become the first, and possibly the worst,
identified serial killer in U.S. history.
When finally caught, he admitted to
killing 28 people, but estimates are that he
murdered, and often mutilated, over 200,
mostly young women. He was hanged in
Philadelphia on May 7, 1896.
The end of the 20th century seems to
have joined the end of the 19th century in
fin de siecle horror. The crimes of Drs
Cream and Mudgett/Holmes have been
echoed in the careers of Britain’s Dr
Harold Shipman and our own Dr Michael
Swango. Dr Shipman was sentenced in
January 2000 to 15 terms of life in prison
for injecting elderly female patients with
fatal doses of heroin between 1995 and
1998. British police estimate that he may
have killed as many as 200 patients in the
same way over his 30 year career. That
would make him the worst serial killer in
British history.
Dr Michael Swango was immediately
arrested by New York authorities after his
recent release from prison, where he had
been serving time for lying on an applica-tion
for a position at a VA hospital. In
early September, he pled guilty to five
felonies, and admitted murdering four of
his patients through lethal injection and
attempting to kill four more. He was sen-tenced
to three consecutive life terms
without possibility of parole. He is sus-pected
of murdering 60 or more patients
during his medical career, which spanned
15 years and took him from Illinois, to
Ohio, to Virginia, to South Dakota, to
New York, and then to Zimbabwe. He
was on his way to another hospital job,
this time in Saudi Arabia, when he was
arrested in Chicago in 1997. His story is
told in chilling detail in James Stewart’s
book Blind Eye.
Sir Arthur Conan Doyle, a physician
himself, had it right.
18 NCMB Forum
Explore the NCMB’s Web Site:
www.ncmedboard.org
The North Carolina Medical Board’s Web site, www.ncmedboard.org, is a straightforward, content-based (no distracting bells and whistles)
source of useful information for the public, licensees, the media, and anyone else interested in the Board and its work. The Site Map below is
featured on the Web site and presents an easy to use guide to the topics covered on the site. Simply click on the Site Map bar in the menu at
the top of the home page, find the item you want on the map, then click – you’ll be there. Exploration couldn’t be easier. Among other things,
you’ll find forms that can be easily printed, the Forum and other publications, an electronic license registration system, information about indi-vidual
licensees, lists of current and past disciplinary actions, and details about the Board and its operation.
Improvements are being made continually to the Board’s site. New features and new information are added regularly. We hope you’ll explore
the site, using the Site Map as your guide, and take advantage of the resources it makes available. And, please, e-mail us your comments and
reactions (public.affairs@ncmedboard.org).
Site Map
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
See Consent Orders:
COBB, Timothy Lee, Physician Assistant
GROGAN, Patricia Jo, MD
ZABENKO, Robert Tracy, DO
SUMMARY SUSPENSIONS
NARA, David Alan, MD
Location: Hancock, MI
DOB: 4/28/1960
License #: 0000-39450
Specialty: GP (as reported by physician)
Medical Ed: Michigan State University (1986)
Cause: Dr Nara may be unable to practice medicine with reasonable skill
and safety by reason of illness, drunkenness, excessive use of alco-hol,
drugs, chemicals, or any other type of material within the
meaning of the statute.
Action: 6/14/2000. Order of Summary Suspension of License issued,
effective on delivery of the Order to Dr Nara. [Notice of
Charges and Allegations issued on 6/14/2000 alleging summary
suspension of Dr Nara’s medical license by the Michigan Board
based on allegations of alcohol abuse and self-prescribing of con-trolled
substances for other than lawful purposes.]
CONSENT ORDERS
COBB, Timothy Lee, Physician Assistant
Location: Yuma, AZ
DOB: 11/20/1948
License #: 0001-00183
PA Education:Duke University (1977)
Cause: Pursuant to an Agreed Order of 4/30/1999, the Texas PA Board
indefinitely suspended Mr Cobb’s Texas license based on his
diversion of certain controlled substances and his conviction for
felony fraudulent delivery of a prescription for a nonmedical pur-pose.
On 10/22/1999, the Texas Board stayed suspension of his
license for 10 years on terms and conditions.
Action: 6/15/2000. Consent Order executed: Mr Cobb’s North
Carolina PA license is suspended indefinitely; that suspension is
stayed for 10 years on condition he comply in all respects with
the Texas Agreed Order of 10/22/1999; must comply with other
conditions.
COHN, Gerald Herbert, MD
Location: Seattle, WA
DOB: 11/19/1928
License #: 0000-38916
Specialty: N/PD (as reported by physician)
Medical Ed: State University of New York, Upstate (1953)
Cause: On 12/19/1997, while preparing to perform a lumbar puncture,
Dr Cohn discharged into the face and eye of an observer a
syringe containing lidocaine through a needle that had just been
withdrawn from the back of a patient. Dr Cohn asserted the dis-charge
was accidental. Certain circumstantial evidence suggests
the act was intentional, while other circumstantial evidence sug-gests
it may not have been. Dr Cohn admits that if the Board
found the act was intentional, that would be immoral or dishon-orable
conduct and unprofessional conduct. He has met with
the Board, has been cooperative, and has seemed genuinely
remorseful for the damage his conduct caused. He no longer
performs lumbar punctures and will not do so in future unless all
persons present take adequate safety measures to protect against
injury and transmission of communicable disease.
Action: 5/12/2000. Consent Order executed: Dr Cohn is reprimanded.
GALEA, Lawrence Joseph, MD
Location: Charlotte, NC (Mecklenburg Co)
DOB: 10/19/1948
License #: 0000-27046
Specialty: FP/GP (as reported by physician)
Medical Ed: University of Cincinnati (1980)
Cause: To amend the Consent Order of 8/23/1999 by which Dr Galea’s
license was reinstated after having been inactive [for failure to
reregister]. The Board summarily suspended Dr Galea’s license
and, thereafter, entered into a Consent Order with him in
December 1991, which was amended in September 1992. He
was relieved of that Consent Order by a Board Order in May
1993. [Details of the earlier actions are available from the
Board.] The Board has agreed to modify the current Consent
Order to take account of his present practice and to make certain
requirements more specific.
Action: 7/21/2000. Consent Order executed: Dr Galea is issued a
license to expire on the date shown on the license (1/31/2001);
he shall submit to and cooperate with a psychological evaluation
and cause a report of that evaluation to be received by the Board
by 10/01/2000; nothing in this Consent Order prohibits or lim-its
the Board from taking any lawful action based on the results
of the evaluation; he shall renew his contract with the NCPHP
and abide by its terms; he shall maintain his NCPHP contract
until the Board orders otherwise; he shall have a female chaper-on
present during all of any encounter he has with a female
patient and the chaperon shall sign and date each patient’s chart,
noting her presence during the encounter; he shall not supervise
PAs, NPs, or nurse midwives in any way; he shall obtain 50
hours of relevant CME each year, 30 hours of which must be in
Category I; must comply with other conditions. The terms and
conditions in this Consent Order supersede those in the 1999
Consent Order imposing any continuing obligation or condition
on Dr Galea, except those imposing a reprimand and regarding
the public nature of the Consent Orders.
GOUBRAN, Michel Zaki, MD
Location: Durham, NC (Durham Co)
DOB: 2/15/1935
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program.
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May-June-July 2000
DEFINITIONS
No. 3 2000 19
License #: 0000-21039
Specialty: OBG (as reported by physician)
Medical Ed: University Ein Shams, Egypt (1962)
Cause: Dr Goubran admits and the Board finds Dr Goubran’s license
was suspended indefinitely pursuant to the Board’s Order of
April 27, 2000; the Board’s Order permits a stay of all but the
first six months of the suspension if Dr Goubran executes a con-sent
order with certain terms and conditions; Dr Goubran
desires to enter into this Consent Order and thereby stay the sus-pension
imposed by the Board’s Order.
Action: 5/24/2000. Consent Order executed: Dr Goubran admits the
findings of fact and conclusions of law set forth in the Board’s
Order, except he denies the stapling [of the medical student’s fin-ger]
was done intentionally; within 60 days of this Consent
Order, Dr Goubran shall obtain an assessment from the NCPHP
and cause a copy of the assessment to be sent to the Board; with-in
one year, he shall obtain at least 40 hours of CME in the areas
of epidemiology and infectious disease prevention, to be
approved in writing by the Board’s president; within one year, he
shall attend and successfully complete a sensitivity training
course, to be approved in writing by the Board’s president; must
comply with other conditions.
GROGAN, Patricia Jo, MD
Location: Smith River, CA
DOB: 7/05/1954
License #: 0000-34020
Specialty: P (as reported by physician)
Medical Ed: State University of New York, Brooklyn (1985)
Cause: This matter regards Dr Grogan’s interaction with patients. Dr
Grogan’s license is currently inactive and she is not interested in
reactivating her registration; during the times relevant to this
matter, she practiced in Pinehurst, NC. The Board received a
complaint from a patient that Dr Grogan engaged in various
boundary violations with the patient. These violations included
Dr Grogan having dinner with the patient in a restaurant and
afterwards the patient spending the night on Dr Grogan’s couch;
they also interacted socially at Dr Grogan’s invitation and Dr
Grogan disclosed personal information to the patient, changed
shirts in front of the patient in a public place, allowed the patient
to help clear her van and garage, and told the patient to call her
Patti. Dr Grogan denies some of this. Another patient com-plained
concerning other boundary violations: repeated requests
by Dr Grogan that the patient interact socially with her and her
children, a request that the patient come to Dr Grogan’s house
to administer homeopathic remedies to Dr Grogan for an
abscessed tooth, Dr Grogan accepting $120 from the patient so
she could obtain dental care, Dr Grogan prevailing on the patient
to search the Internet for prospective buyers for her medical
practice, Dr Grogan drinking beer during treatment sessions, and
Dr Grogan calling the patient at home to ask advice about per-sonal
problems. Dr Grogan denies some of this. Dr Grogan
admits she wrote a letter to the referring physician’s office admin-istrator
in which she disclosed confidential information about the
first patient without permission. She also admits she nursed one
of her children in front of male and female patients during vari-ous
treatment sessions; although at the time she believed the
patients consented to her doing this, she now understands that it
was unprofessional even if they consented. She also admits she
hired another patient to work in her office as an administrative
assistant.
Action: 6/22/2000. Consent Order executed: Dr Grogan’s license is sus-pended
for 60 days and the suspension is stayed for one year on
the following terms and conditions. Dr Grogan shall establish a
counseling relationship with an app

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
Choosing the Right Words, the Right Place,
and the Right Time .........................................1
From the Executive Director:
Feedback .........................................................1
Dialogue on Public Health.................................3
NCMB Announces Hiring New Medical
Coordinator: Gary M. Townsend, MD, JD ....5
Battered Men: Another Story .............................6
Using the NCMB’s DataLink Software ..............7
Position Statement on Office-Based Surgery.......7
Prescriptions: Legal and Legible.........................8
From the NC Board of Pharmacy:
Focus on Prescriptions .......................................9
Treating Bias ....................................................10
President’s
Message
From the
Executive
Director
Wayne W. VonSeggen, PA-C Andrew W. Watry
No. 3 2000
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Choosing the Right
Words, the Right Place,
and the Right Time
The Right Words
In the work of the North Carolina
Medical Board, we are challenged to license
and discipline and to properly regulate the
practice of medicine and surgery in North
Carolina for the benefit and protection of
the public. In the position statements and
the various motions that the Board considers
and acts upon, the Board must carefully and
cautiously use the appropriate words to con-vey
the principles involved. The Board often
attempts to clarify the words by defining
them with great precision. Some of the
more challenging words recently addressed
have been “injection,” “surgery,” “invasive
procedure,” “scope of practice,” “compe-tence,”
and “continuing medical education.”
In the area of scope of practice, the Board
accepts the fact that, more often than not,
the scope of practice for a given profes-sion
has already been
determined by the
North Carolina Gen-eral
Assembly, and
codified in statute,
with regulations to
clarify the remain-ing
issues. Sometimes,
the General Assembly
has chosen to leave
certain issues unde-fined,
with some pro-fessions
struggling to
implement their own nationally promulgat-ed
and hopefully successful scope of practice.
Occasionally, when new professions arrive
on the health care scene, there is inevitable
overlapping of skill bases. Often these can
be worked out on a national basis, with indi-vidual
professions hoping to stake a claim to
a particular “scope of practice” by their own
definition. In North Carolina, we have
recently experienced significant differences
Feedback
This article appears opposite a message
from the Board’s president, Mr Wayne
VonSeggen, which, in this instance, is
particularly poignant for me. His topic,
choosing words carefully, covers an area to
which I need to devote some attention. So,
in an abundance of caution, I consulted
Merriam-Webster’s Collegiate Dictionary. The
first definition of feedback is: “the return to
the input of a part of the output of a
machine, system, or process (as for produc-ing
changes in an electronic circuit that
improve performance or in an automatic
control device that provide self-corrective
action).” The Board may be viewed as a
control device for public protection, man-dated
by the public
through legislation.
A similar device
exists in our 49
constituent states,
as well as a majori-ty
of countries and
other political sub-divisions
through-out
the world.
In our jurisdiction, we pay particular
attention to feedback. This is done through
a variety of mechanisms. The principal
mechanism is the work of the Board’s Public
Affairs Department, of which this publica-tion,
the Forum, is a major product. Another
important element of that department’s
activity is the posting of public information
for consumers and licensees both on the
printed page and on our Web site. Feedback
is vitally important to the Board, allowing us
to identify and implement self-corrective
action.
forum
continued on page 3
continued on page 2
A Brief Guide to CME Requirements for
Physicians in North Carolina........................10
The Physician Assistant ....................................13
Letters to the Editor:
Legislation Is the Best Solution to Records Problem;
And More on Medical Records;
Male Victimization........................................14
Vital Information Required by the NCMB.......15
Review:
Doctor Death: The Ultimately Impaired
Physician.......................................................16
Explore the NCMB’s Web Site .........................18
Board Actions: 5/2000-7/2000 ........................19
Board Calendar ................................................23
Change of Address Form..................................24
License Registration .........................................24
POSITION STATEMENT ON
OFFICE-BASED SURGERY – PAGE 7
BRIEF GUIDE TO NCMB
CME REQUIREMENTS – PAGE 10
“Feedback is
vitally important
to the Board,
allowing us to
identify and
implement self-corrective
action”
“In North
Carolina, we
have recently
experienced sig-nificant
differ-ences
of opinion
about ophthal-mology
and
optometry scopes
of practice”
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. V, No. 3, 2000
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Wayne W. VonSeggen, PA-C
President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Vice President
Raleigh
Term expires
October 31, 2002
Walter J. Pories, MD
Secretary-Treasurer
Greenville
Term expires
October 31, 2000
George C. Barrett, MD
Charlotte
Term expires
October 31, 2002
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2001
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Paul Saperstein
Greensboro
Term expires
October 31, 2001
Aloysius P. Walsh
Greensboro
Term expires
October 31, 2000
Martha K. Walston
Wilson
Term expires
October 31, 1999
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Assistant Editor
Shannon L. Kingston
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.ncmedboard.org
E-Mail:
info@ncmedboard.org
Choosing the Right Words
continued from page 1
of opinion about ophthalmology and
optometry scopes of practice, primarily
regarding whether an injection should or
should not be considered surgery. The
optometry statute specifically excludes
surgery from the scope of practice of optom-etry.
The North Carolina Medical Board
continues to work toward a clearer under-standing
between these groups of highly
skilled health care practitioners. It is a work
in progress.
Conceptually, scope of practice is different
from the standard of care, which more accu-rately
describes what is currently being done
in a certain locality. When the standard of
care for a profession exists, can it ever
change? Is the standard of care a local phe-nomenon?
Or is it a statewide phenome-non?
Or is it, finally, determined nationally?
When a possible change in the standard of
care for a particular profession is acknowl-edged,
from whose perspective is that stan-dard
of care determined: the professionals
who support the new standard or the aver-age
citizen-patient? Scope of practice, being
defined principally by statute, is more than a
wishful expectation, it is a legal boundary
that requires careful analysis of the law as
well as issues such as training, experience,
and public safety.
At issue is the responsibility and duty of
regulatory boards themselves. How far can
the regulatory board proceed with defin-ing
words, concepts, and overlapping scopes
of practice while still
performing the pri-mary
function of
protecting the pub-lic?
While each profes-sion
seeks to carve
out its niche in the
health care arena,
there is potential
conflict ahead when one profession signifi-cantly
infringes on the scope of another. If
the General Assembly does not provide clear
definitions, the responsibility could arrive
back at the door of the North Carolina
Medical Board, which has been given the
authority to regulate the practice of medi-cine
and surgery. So far, the Board has taken
what it considers to be thoughtful and
responsible actions in various areas affecting
physicians, surgeons, physician assistants,
nurse practitioners, nurse midwives, EMS
personnel, resident physicians, and other
health professions, such as clinical pharma-cist
practitioners, optometrists, and pharma-cists.
The Right Place
Take your pick...a court of law, the legisla-ture,
the professional organization, or the
regulatory board? At one time or another,
each of these has driven decision-making on
particular issues. For example, in 1997,
under Senate Bill 945, the General Assembly
directed that “drugs identified as having nar-row
therapeutic indices shall be designated
by the North Carolina Secretary of Human
Resources upon the advice of the State
Health Director, North Carolina Board of
Pharmacy, and the North Carolina Medical
Board.” As a result, each year the process of
identifying those drugs that fit into this cat-egory
falls to those entities given authority
by statute. The Board is aware that the leg-islature
may choose to write statutes that
direct one or more regulatory boards to
work out the regulatory details of a particu-lar
issue.
The North Carolina Medical Board urged
passage of House Bill 1049 in the 1999 and
2000 sessions of the General Assembly to
attempt to improve the ability of the Board
to properly regulate and discipline physi-cians
and to make the unlicensed practice of
medicine a felony instead of a misdemeanor.
However, the General Assembly balked on
the latter point when a cadre of naturopath-ic
and homeopathic practitioners and their
supporters voiced vehement opposition to
it. Legislators heard the unlicensed practi-tioners
talk publicly about their practices,
knowing that those practitioners have no
statutory basis for practice in this state at this
time. Not a single legislator publicly
remarked about the lack of statutory author-ity
in North Carolina to practice naturopa-thy
or homeopathy. Grassroots activism,
including e-mail, letters, and telephone calls,
forced modification of the bill on that issue.
And finally, the entire bill died for lack of
action by the Senate.
Six years ago, when optometrists strove to
include 150 additional CPT codes in their
scope of practice, the ophthalmologists and
other physicians and surgeons, and even the
Medical Board, became active at the judicial
level to block such action. To resolve such
attempts to expand the scope of optometry,
a Consent Agreement was signed under
which such changes must be approved by all
the disputing parties that signed the agree-ment,
including the Medical Board. Since
then, further requests for modification of
continued on page 3
“There is poten-tial
conflict
ahead when one
profession signif-icantly
infringes
on the scope of
another”
No. 3 2000 3
Feedback continued from page 1
Legislative Lessons Learned
An example of self-corrective action is
found in the Board’s recent attempt to bring
improvement to its statutory foundation, the
Medical Practice Act (MPA). Under North
Carolina law, the Board cannot use any funds
to promote or oppose legislation. It must,
therefore, rely on legislative leadership to
shepherd corrective actions. Unfortunately,
while the Board’s legislative initiative
(House Bill 1049) passed the House in this
last session, it died in the Senate due to
strong opposition to the bill in that chamber.
The Board will be evaluating the feedback
from this process to determine how best to
achieve in the next legislative session the
improved approaches to public protection it
seeks. The following is some feedback gen-erated
in the course of this recent legislative
experience.
The Board sought to make the penalty
for the unlicensed practice of medicine a
felony instead of a misdemeanor. There
was substantial opposition to this provision
from supporters and practitioners of so-called
alternative medicine. Some of these
were duly licensed
physicians. The
legislation was per-ceived
as a threat to
alternative medi-cine.
In actuality,
the legislation did
not change in any
way what consti-tutes
legal or illegal
behavior by unli-censed
persons. It
only changed the penalty for engaging in
such illegal behavior. The legislation, how-ever,
was painted as an attack on practices
such as naturopathy and homeopathy.
There are no naturopathic or homeopathic
licensing statutes in North Carolina, and,
thus, there are no licensing boards for
naturopathy and homeopathy. Yet, several
persons identifying themselves as natur-opaths
testified about the validity of their
practices and the threat presented by
increasing the penalty for their unlicensed
activities.
In the House, there was an amendment to
HB 1049 to set up a legislative research
commission to look at all the issues con-cerning
these various unlicensed practition-ers,
but the amendment, along with HB
1049, died in the Senate. The feedback we
received in connection with this legislative
optometry’s scope of practice have surfaced
periodically. However, due to the Consent
Agreement, unless every party to the agree-ment
approves, NO CHANGE CAN TAKE
PLACE! One has to wonder whether such
an agreement is the right vehicle for the
determination of the scope of practice, or
whether it is time for the General Assembly
to clarify its intent concerning the scope of
practice of optometry.
Political powers should tread gently in
determining the scope of practice of health
care professions, especially when ethical con-siderations
in government cry out for fair
play and equal rights for everyone’s profes-sion.
Regulatory boards derive all their
authority from legislatures. Hence, regula-tory
boards should stay within their areas of
responsibility.
The convergence of events sometimes
enlightens us to the irony of these endeav-ors.
Within the same month the North
Carolina Medical Board heard ophthalmolo-gists
state that there was no possible way
that an injection in any form by an
optometrist could be considered within the
scope of practice of optometry, we heard
pharmacists asking for the ability to expand
their scope of practice to give multiple types
of injections at pharmacies, outside the
purview of the patient’s personal physician.
Thousands of insulin-regulated diabetics
inject themselves every day in North
Carolina and no one has considered this to
be “practicing surgery.” Nurses provide
injections regularly with skill and predictably
excellent outcomes for millions of our citi-zens
and it is not considered “practicing
surgery.” This all brings me to the last point.
The Right Time
Medical knowledge marches on. Modern
medical technology will always push us to be
faster, more precise, more efficient, with
higher quality and improved outcomes.
That is the nature of progress. Every med-ical
professional struggles to keep up with
the ever-expanding database and skill
requirements in medicine. Do our continu-ing
education attempts really ensure our
competence? Do the acquired skills you
have learned since your graduation from
professional school mean anything? Of
course they do! Your database is better, and
your skills are at a higher level. Are the skills
you have acquired since your licensure as a
health professional of any real value? Of
course they are! Does all this medical train-ing
after licensure or after graduation affect
your scope of practice? It all depends on
whom you ask! Some say, “Training does
not necessarily change your scope of prac-tice.”
The easy answer is to agree that if you
really do know what you’re doing in your
specific piece of the medical specialty you
practice, then you will likely be able to pull
it off. You provide top-notch health care ser-vices,
probably within your scope of practice
and standard of care. You feel comfortable.
The patient gets good service. Everyone is
happy...unless you have trodden into anoth-er
profession’s scope of practice. You may
then need to look to your attorney for guid-ance,
or call your legislator and get everyone
else to do the same. Remember that democ-racy
is the will of the people, but there are
definitely principles involved. Grassroots
activism cannot totally obviate principle.
The Medical Board works to balance the
issues on the principles involved in our pro-gressive
medical environment. The Board
believes that it has the authority to regulate
the practice of medicine and surgery and to
refer for legal action any situation that might
be considered the unlicensed practice of
medicine. Sometimes we take action, and
sleep soundly. Other times, we second-guess
ourselves, review issues again, and strive for
the solution. Jim Elliott, a missionary to the
Auca Indians in Peru, once said, “Indecision
is the true enemy of successful perfor-mance.”
At times, we push to make a deci-sion
and must reconsider certain actions in
light of additional information. The strug-gle
is to use the right words, in the right
place, and at the right time.
Choosing the Right Words
continued from page 2
continued on page 4
“It seems pru-dent
to separate
the issues affect-ing
unlicensed
people from the
issues of improv-ing
the process
for licensed
physicians”
Dialogue on Public Health
Public health issues are a concern, not only
for the medical community, but also for indi-viduals
and families across North Carolina.
Now there’s a forum to discuss many of
those issues and to provide accurate, up-to-date
information to the public as well. A 12-
month series of call-in programs on the
Open Public Events Network (OPEN)
begins with a discussion about asthma on
November 16 at 9:00 PM. The call-in series,
which is sponsored by the Division of Public
Health, Department of Health and Human
Services, will continue on the second
Thursday of every month at 9:00 PM on var-ious
public health topics.
OPEN programs give citizens an opportu-nity
to call in and talk with public officials
about a broad range of topics of statewide
interest every Tuesday and Thursday from
8:00-10:00 PM. For a list of cable systems
carrying OPEN programs, including
the series on public health, or to receive
monthly program schedules, call 919-733-
6341, e-mail open@ncmail.net, or go to
www.doa.state.nc.us/doa/apt/cablelst.htm.
effort seemed to paint the Board as a group
of physicians trying to protect its turf and
exclude so-called alternative medical practi-tioners
from the market place. From the
Board’s perspective, this is certainly not the
case. The Board recognizes the significant
marketplace in alternative medicine (by
some estimates, a 4 billion dollar a year
enterprise) and the importance of physi-cians
having a working knowledge of alter-native
medical practices (many of
their patients may be taking alter-native
substances that can inter-act
with prescribed medicines).
The Board was simply concerned
that there are individuals engag-ing
in activities that are defined in
the MPA as the practice of medi-cine
who have had no screening
and validation for training cre-dentials,
have passed no licensing
examination, and have no licens-ing
board as a recourse for consumers who
are dissatisfied or in some way harmed. In
short, they are in violation of the MPA.
These individuals are unaffected by the
penalty for unlicensed practice as it now
exists and the Board proposed a remedy. As
I’ve noted, there was a significant backlash
in the legislature to this proposed remedy.
The Board is reassessing what consumers
in this state expect from its licensing system
and whether the Board or some other enti-ty
should be the catalyst for corrective
action in light of substantial consumer
response. Unfortunately, this consumer
response had the effect of chilling the
Board’s recommended improvements in
other important areas with respect to pub-lic
protection mechanisms involving physi-cian
licensees. The Board will deliberate
over the lessons learned. At the very least,
it seems prudent to separate the issues
affecting unlicensed people from the issues
of improving the process for licensed physi-cians.
Pain Management and Drug-Seekers
The Board members and staff spend a lot
of time giving speeches to various organiza-tions
such as hospitals, medical societies, and
consumer groups. This provides a valuable
feedback mechanism. The following is an
example of feedback from some recent activ-ities.
The Position Statements of the North
Carolina Medical Board includes a state-ment
on the management of chronic non-malignant
pain. The beginning of that
statement reads: “It is becoming increas-
4 NCMB Forum
Feedback
continued from page 3
ingly apparent to physicians and their
patients that the use of effective pain man-agement
has not kept pace with other
advances in medical practice.” It goes on to
define pain categories and appropriate
mechanisms for treating chronic pain,
including a list of 11 suggested elements
for effective management. It ends with the
comment that no physician need fear
reprisals from the Board for appropriately
prescribing, as outlined in the statement,
even large amounts of controlled sub-stances
indefinitely for chronic non-malig-nant
pain. This position state-ment
is consistent with national
recommendations and guidelines
intended to sensitize physicians to
suggestions that chronic non-malignant
pain may be inade-quately
medicated by some physi-cians
who fear medical board
intervention.
When presented to practitioners
in the field, including hospital
physicians and pharmacists, this
statement is well received, but there is feed-back
about a real-life situation that
also plagues these practi-tioners:
professional drug-seek-ing
patients. The existence of
these so-called patients in all
state medical board jurisdic-tions
is well documented. They
are particularly well document-ed
in states where there are trip-licate
prescription programs
documenting their activity, such
as seeking controlled substances
from several physicians and
pharmacies simultaneously.
An example of a patient
encounter that presented a
dilemma for a practicing physician was
raised at a recent meeting. A physician
described a patient he suspected was abus-ing
controlled substances, he referred the
patient to a pain clinic, and the patient
responded to the physician that if the physi-cian
did not continue to maintain his pre-scribing
for the patient, the patient would
burn the physician’s house down. This is
an extreme example of a drug-seeking
patient who is engaging in criminal behav-ior
and, in the process, is pressuring pre-scribing
physicians and dispensing pharma-cists
to aid in the criminal behavior. This is
a concept that is often referred to by feder-al
authorities as concurrent liability: pre-scribing
physicians and pharmacists can be
considered engaging in illegal activity for
participating in obvious criminal behavior,
the diversion of controlled substances. The
message from this session was that, while continued on page 5
we have focused a lot of necessary attention
on the importance of managing chronic
non-malignant pain, we must also consider
helping those practitioners who daily face
the dilemma presented by drug-seeking
patients – avoiding any involvement in ille-gal
diversionary schemes.
Views on Discipline
Yet another message comes from our crit-ics,
who at times seem abundant. Medical
boards are either doing too much or too lit-tle
in terms of disciplinary orders. Of
course, there is far more criticism in the lat-ter
category.
This Board receives over 600 com-plaints
from patients each year. Most of
these are triggered by poor communica-tion,
which may or may not be coupled
with poor outcome or unprofessional
behavior. Most everyone who complains
expects a disciplinary action in response.
Then there is the licensee. He or she reads
the last four or five pages of the Forum and
regularly sees what peers are sanctioned for.
At times, it appears all you have to do is
have a bad day at the office and you are
branded for the rest of your career. This
fear is exacerbated when read-ing
the summary narrative
behind the reported actions.
Licensee feedback suggests that
what sometimes appear to be
relatively minor incidents result
in public discipline. From the
Board’s perspective, minor
incidents don’t result in public
disciplinary action. There is
full due process afforded by law
before any public disciplinary
action is taken, and the events
leading to such action have to
be supported by a preponderance of the
evidence. No one gets a public disciplinary
action without opportunity for a hearing
unless there is imminent risk to the public
health, safety, and welfare that requires
emergency action. In those few cases
requiring emergency action, a licensee has
an opportunity for an expedited hearing.
The due process mechanisms available to a
licensee are perhaps not apparent to those
licensees who read the list of actions in this
publication, and a licensee may be left with
the impression he or she could end up on
these pages simply for being the target of a
vitriolic patient.
These divergent reactions from consumer
groups and complainants on one side and
licensees on the other are constant for most
medical boards. A simplistic view (mine) is
that medical boards function on a continu-
“There is feed-back
about a
real life situa-tion
that
plagues these
practitioners:
professional
drug-seeking
patients”
“No one gets a
public disciplinary
action without
opportunity for a
hearing unless
there is imminent
risk to the public
health, safety, and
welfare that
requires emergency
action”
No. 3 2000 5
Where should a medical board be on this
continuum? Perhaps it belongs somewhere
in between, tilting in favor of the con-sumers
that medical licensing laws were
designed to protect while providing full
due process afforded by law to licensees.
That means some bad outcomes and con-sumer
complaints will go unpunished.
Meanwhile, critics on either end of the con-tinuum
will not be happy. Most medical
boards get negative feedback from those
who advocate more extreme ends of
the continuum. This feedback is impor-tant
to our Board, even though it is almost
always negative. Feedback tells us we need
to work both sides of the argument.
We must be responsive to concerns
of consumers about
public protection
and to concerns of
licensees and their
lawyers that we act
within the law and
afford full due
process protections
of the law. An
argument can be
made that if a med-ical
board is being
criticized from both extremes, it is probably
moving in the right direction in terms of
protecting the public. People on both sides
of the issue need to know what this Board
is doing to protect their interests, and we
make every effort to let them know.
Conclusion
These are but a few examples of this
Board’s sensitivity to feedback. The Board
members and staff are readily available to
meet with any group to explore these and
other issues. We routinely meet with med-ical
society groups, hospital staffs, medical
students, deans of the medical schools, civic
groups, legal groups, and associates in other
states for this purpose. The Board’s current
president, Mr Wayne VonSeggen, has
appeared before a dozen or more groups
during his presidential year. Its upcoming
president, Dr Elizabeth Kanof, is already
planning a special group of presentations
across the state. This represents part of our
continuing effort to solicit your input and
feedback. You can give us your comments
by e-mail (info@ncmedboard.org), by fax
(919.326-1130), by post (PO Box 20007,
Raleigh, NC 27619), or by telephone
(919.326-1100/800.253-9653), as you
deem appropriate. If you would like a rep-resentative
of the Board (Board members
and/or staff) to address your group or orga-nization,
please let us know and we will do
our very best to accommodate you.
Feedback
continued from page 4
“An argument
can be made
that if a medical
board is being
criticized from
both extremes, it
is probably mov-ing
in the right
direction”
um. At one end, the board clearly doesn’t
do its job. Licensees who are outliers are
100% happy – no one gets disciplined.
(Notice that I qualified the licensee
response. I think the majority of good and
diligent physicians would be unhappy
because the outliers would represent a sig-nificant
blight on their profession. This
would have a negative impact on them and
the medical community. For the sake of
simplicity in outlining the continuum con-cept,
we will leave this majority of licensees
out.) At the same time, consumers are
unhappy. No one is protecting them from
outliers in the licensee population. At the
other end of this continuum, the board is
draconian – it imposes discipline as a result
of almost all complaints; thus most of the
complainants are happy. Licensees are
unhappy – they do not have due process
protection. Every time a complaint comes
in, a physician is sued, or there is a bad
medical outcome, someone is disciplined.
The board is fully responsive to its con-sumer
critics. Consumers don’t complain
about the board, but licensees do. The
board works on the assumption that a com-plaint
must have merit or a bad outcome
must be punished. On this end of the con-tinuum,
there is a true sense of urgency.
The magnitude of the consequences of
medical error are staggering. A summary
of the Institute of Medicine report en-titled
To Err Is Human: Building a Safer
Health System (which may be found at
http://books.nap.edu/catalog/9728.html) finds
that “... as many as 98,000 people die in
any given year from medical errors that
occur in hospitals. That’s more than die
from motor vehicle accidents, breast cancer,
or AIDS – three causes that receive far
more public attention. Indeed, more peo-ple
die annually from medication errors
than from workplace injuries. Add the
financial cost to the human tragedy, and
medical error easily rises to the top ranks of
urgent, widespread public problems.”
Some consumer watchdog agencies tell us
that medical boards should be taking many
more disciplinary actions – in effect, we
need a substantial phase shift on the con-tinuum.
This may be true, but there are
some with unrealistic expectations. An
extreme view, one taken at the polar end of
the continuum, is that malpractice equates
with incompetence and medical error
should necessarily be met with a punitive
response. (By the way, a medical board
could only function on this end of the con-tinuum
in another country, because there
would be no due process for the licensee.)
NCMB Announces
Hiring New Medical
Coordinator:
Gary M. Townsend,
MD, JD
Andrew W. Watry, executive director of the
North Carolina Medical Board, has
announced that Gary M. Townsend, MD, JD,
a native of Virginia, has been selected to
replace Jesse Earle Roberts, Jr, MD, as the
Board’s medical coordinator. Dr Roberts left
the medical coordinator’s position in March
2000 after almost three years of service.
Following his graduation from Duke
University in 1972, Dr Townsend received his
MD degree from West Virginia University in
1976. He obtained his JD from George
Washington University in 1980. He has been
licensed to practice medicine in North
Carolina since 1979 and is also licensed in
Maryland, Pennsylvania, Virginia, and West
Virginia. He is a member of the bar in
Pennsylvania and West Virginia.
Dr Townsend has practiced emergency
medicine since 1978 in Pennsylvania and
Maryland, and most recently at Dorchester
General Hospital in Cambridge, Maryland.
He has also practiced as a medical-legal con-sultant,
first on active duty with the U.S. Air
Force from 1986 to 1992, and, from then
until the present, as a civilian with the
Consultation Case Review Branch of the
Office of the Surgeon General, U.S. Army
Quality Management Directorate, located at
Walter Reed Army Medical Center in
Washington, DC.
A flight surgeon with the 167th Airlift
Wing of the West Virginia Air National
Guard since 1994 and commander of the
167th Medical Squadron since 1997, Dr
Townsend holds the rank of colonel.
His duties with the Consultation Case
Review Branch were quite similar to the tasks
he will undertake for the Board. The medical
consultant’s role is to assist and advise the
Board and the staff in areas requiring general
medical expertise and in the screening and
evaluation of complaints involving medical
care issues.
“We are delighted to welcome Dr
Townsend to the Board’s staff,” Mr Watry
said, “and are pleased with the experience and
expertise he brings to the position of medical
coordinator. Over the past three years, our
case review systems have improved remark-ably
thanks to the efforts of our outstanding
Complaints Department staff and to the hard
work and dedication of our first medical coor-dinator,
Dr Roberts. Dr Townsend is well
equipped to continue in that tradition and
add to it in meaningful ways. We look for-ward
to working with him.”
6 NCMB Forum
Abused men, too, are just as concerned for
their children and want the family unit to
remain in tact. Moreover, since women still
get physical custody
of children in over
85% of all divorce
cases, many men are
hesitant to leave, real-izing
that if they do
the courts may
severely limit their
access to their chil-dren.
For men, deciding to leave an abusive rela-tionship
is only half the battle. The other
half is: where do they go, who will believe
them? It seems that, in reality, barriers to a
male victim of domestic abuse are very much
the same as those facing a female victim just
a few short years ago.
Conclusion
Resources and facilities to combat domes-tic
violence are out there, but, unfortunately,
are still in short supply. Perhaps some bat-tered
women’s groups fear that if society rec-ognizes
that men are victims too, what little
money that is available will be diverted.
Continuing to portray partner violence
solely as a women’s issue is wrong, it is
counterproductive. No one has a monopoly
on pain and suffering. Until society recog-nizes
all the victims of domestic violence, we
will never be able to solve the problem.
Domestic violence is neither a male nor a
female issue – it is a human issue.
“Continuing to
portray partner
violence solely as
a women’s issue
is wrong, it is
counterproduc-tive”
Domestic Violence: Part 2
Battered Men: Another Story
Laura A. Queen
Outreach Coordinator, Women’s Aid In Crisis, Upshur County, WV
Billboards and radio and television ads
across the country proclaim that every few
seconds a woman is beaten by a man.
Violence against women is clearly a problem
of national importance. The United States
Department of Justice estimates that 95% of
reported assaults on spouses or ex-spouses
are committed by men against women. In
the three years I have been a domestic vio-lence
victim advocate in this county, I have
provided services to 450 clients, 10 of whom
were males.
Why the Silence?
While the very idea of men being abused
by their partners runs contrary to many of
our deeply ingrained beliefs about men and
women, female violence against men is a
phenomenon almost completely ignored by
the media and society.
Violence takes on many forms. There is
no question that since men are, on average,
bigger and stronger than women, they can
do more damage in a physical assault.
However, not all men are bigger than their
female partners and not all abuse is physical,
a fact that is pointed out over and over when
describing domestic violence.
And what of female-on-male violence?
Why don’t we hear about it more often? For
several reasons. First,
men in general are
extremely reluctant to
report that they have
been the victims of
any assault. After all,
men are supposed to
be tough, able to take
care of themselves,
right? What would
people think. . . ? Men are trained to solve
their own problems, not to ask for help.
Second, confessing to being knocked around
by another man is a piece of cake compared
to admitting being abused by a woman.
Why? Most likely, men fear, rightly so, soci-ety’s
traditional reaction. In France in the
eighteenth and nineteenth centuries, a hus-band
who had been pushed around by his
wife would be forced by the community to
wear women’s clothing and to ride through
the village sitting backwards on a donkey,
holding its tail.
The Female Potential for Violence
There are several serious effects of soci-
“Female vio-lence
against
men is a phe-nomenon
almost com-pletely
ignored
by the media
and society”
ety’s reluctance to acknowledge the female
potential for violence. First, women are sub-tly
encouraged to be more violent, eg, moth-ers
tell their daughters: “If he gets fresh,
slap him.” Second, while it is possible to
argue that a slap is unlikely to do any severe
damage, not recognizing that a slap is still
violence sets a dangerous precedent.
Arresting a man who slaps a woman, while
dismissing a woman’s slapping of a man as
nothing to worry about, both condones vio-lence
and reinforces a double standard that
historically has been used to oppress women
in the name of protection.
Men’s victimization cannot be denied,
however a few questions still remain. First,
if men are so much bigger and stronger, why
don’t they protect them-selves?
The answer
makes perfect sense. At
the same time little girls
are being told it is okay
to slap, little boys are
being told, “Never hit a
girl.” And when these
little boys grow up, they
are told that any man who hits a woman is a
bully. But if a woman hits him, he is sup-posed
to “take it like a man.” Also, many
men recognize the severe damage they are
capable of doing and, therefore, consciously
try to limit it. One male client I worked
with stated that his partner used the knowl-edge
that he would not strike back and con-tinued
the abuse. Another, after years of
physical abuse at the hands of his wife,
struck her in the face after she assaulted him.
She called the police, who, upon arrival,
arrested him for domestic battery, not believ-ing
his story that she struck first.
Leaving the Relationship
Not fighting back is one thing, but why
would any sane person stay in an abusive
relationship? I have learned in advocating
for men as victims that their reasons differ
little from women’s.
Economics plays a part. As more women
enter the work force, it is getting harder and
harder to find a traditional “man-as-the-sole-breadwinner”
family. Men are becoming
more dependent on their partners’ incomes
for family survival.
Many women fear that if they leave their
husbands, the violence they have experi-enced
may be directed against their children.
“Why would
any sane
person stay
in an abu-sive
relation-ship?”
About the Author
Ms Queen is the author of the article on
domestic violence that appeared in the previ-ous
number of the Forum. She is a talented
West Virginia artisan who, along with her
husband, handcrafts unique and beautiful
kitchen utensils from native woods: maple,
cherry, walnut, and hickory. Much of her
time is spent in the frontline fight against
spouse and child abuse. She has helped res-cue
hundreds of women and children from
all types of abuse, assisting them in putting
their lives back together. As this article
makes clear, she is also no stranger to the
abuse of men by their female partners. Her
voice has the ring of truth tempered by expe-rience
and she can tell stories that will bring
tears to anyone’s eyes.
No. 3 2000 7
At its meeting in September, the North
Carolina Medical Board adopted the follow-ing
Position Statement on Office-Based
Surgery.
Office-Based Surgery
Office-based surgery is surgery* per-formed
outside a hospital or an outpatient
facility accredited by the North Carolina
Division of Facility Services. Although
surgery is not a perfect science in any setting,
office-based surgery is generally safe, effec-tive,
and efficient, provided proper measures
are taken in the process. It is the position of
the North Carolina Medical Board that the
physician is responsible for providing a safe
environment for office-based surgery.
The following general guidelines are rec-ommended
for office-based surgery.
Training:
Any procedures, whether done in an office
or a hospital, should be performed by
physicians operating within their area of
professional training. Appropriate train-ing
and continuing medical education
should be documented and that documen-tation
should be readily available to
patients and the North Carolina Medical
Board. Those who perform office-based
surgery must have plans, such as pre-arranged
hospital admission protocols, for
managing emergency complications.
Patient Selection:
Patients must be evaluated per procedure
to determine if the office is an appropriate
setting for the surgery.
Patient Evaluation:
Patients undergoing office surgery must
have an appropriately documented history
and physical examination, and any other
studies or consultations indicated.
Anesthesia:
When general anesthesia or sedation is
provided in the office setting, it must be
administered by those qualified to do so.
Anesthesia personnel should be familiar
with variations in technique based on the
specifics of the patient and the procedure,
particularly those requiring large volumes
of fluids or airway management. Patients
must be properly monitored before, dur-ing,
and after the procedure. Physicians
are referred to the protocols of the
American Society of Anesthesiologists**
for guidance. ACLS certification of anes-thesia
personnel is an important consider-ation.
Office Setting:
The office should be set up with patient
safety as a primary consideration. Safety
issues should include, but not be limited
to, accessibility, sterilization and cleaning
routines, storage of materials and supplies,
supply inventory, and emergency equip-ment.
Emergency Planning:
Planning should include, but not be limit-ed
to, emergency medicines, emergency
equipment, and transfer protocols.
Practitioners should be trained and capa-ble
of managing complications related to
the procedures they perform.
Follow-Up Care:
As with any surgical treatment or proce-dure,
follow-up care by the responsible
surgeon is requisite. Arrangements
should be made for follow-up care and for
treatment of problems or complications
outside normal office hours.
Quality Improvement:
Continuous quality improvement should
be a goal.
.........................
* Definition of surgery as adopted by
the NCMB, November 1998:
“Surgery, which involves the revision,
destruction, incision, or structural
alteration of human tissue performed
using a variety of methods and instru-ments,
is a discipline that includes the
operative and non-operative care of
individuals in need of such interven-tion,
and demands pre-operative
assessment, judgment, technical skills,
post-operative management, and fol-low
up.”
** “Guidelines for Office-Based Anes-thesia,”
“Guidelines for Ambulatory
Anesthesia and Surgery,” “Basic
Standards for Preanesthesia Care,”
“Standards in Basic Anesthetic
Monitoring,” “Standards for Post-anesthesia
Care,” “Guidelines for
Nonoperating Room Anesthetizing
Locations.” All available from the
American Society of Anesthesiolo-gists.
[Adopted September 2000]
NCMB Adopts Position Statement on
Office-Based Surgery
About five years ago, a group of members
from our professional organization, the
North Carolina Association of Medical Staff
Services (NCAMSS), met with Bryant D.
Paris, Jr, then executive director of the North
Carolina Medical Board (NCMB), and H.
Diane Meelheim, assistant executive director
of the NCMB, to discuss what information
would be helpful to the medical staff profes-sional
if it were available on software. A sec-ond
meeting was held on April 3, 1998.
Three of us from the NCAMSS, Kay
Gibson, Deborah Chapman, and Donna
Masho, attended the meeting. Attending
from the NCMB were its then new execu-tive
director, Andrew W. Watry, Ms
Meelheim, and Rebecca Manning. The pur-pose
of the second meeting was to discuss
the software of the NCMB’s DataLink sys-tem,
problems encountered in medical staff
offices, and the benefits derived from having
access to practitioner licensing information
on a continuing basis.
Problems and Solutions
The main point of our discussion at the
April 3 meeting was the new state guideline
for license renewal dates (annually, on the
practitioner’s birthday). It has had an
impact on the medical staff office because of
a 60-day period that the license may be in
limbo due to the wording of the statute. It
was the consensus of the group that there
was not much we could do about the way
the statute is worded, but that we could
work toward establishing a process that
would be acceptable to the NCMB, hospi-tals,
and licensing and accrediting agencies.
A medical staff professional’s worst night-mare
would be finding an unlicensed physi-cian
on the staff of his or her hospital.
Those of us from NCAMSS found Diane,
Rebecca, and Andrew to be very aware and
concerned about our problems, with a real
willingness to help correct them. Several
ideas were discussed. We all agreed that the
more we can do through the software pro-gram,
the better it would be for everyone.
For example, added to the program was to
be a tickler file informing us of the date on
which the Board sent the letter of renewal to
the physician, who has 30 days to respond.
Using the NCMB’s
DataLink Software
Donna Masho, CMSC
Alamance Regional Medical Center
Kay Gibson, CMSC
High Point Regional Health System
continued on page 12
8 NCMB Forum
Prescriptions: Legal and Legible
Donald R. Pittman, Field Supervisor
NCMB Investigative Department
A pad of prescription blanks is found in
every physician’s office from Murphy to
Manteo, and as long as one is readily avail-able
to the physician, who gives it a second
thought? Please read on, you may learn that
many have and are giving the physician’s
prescription blank a second thought!
Pharmacists, nurses, patients, and regulatory
board investigators have all raised questions
about the pre-printed information and the
handwriting on the physician’s prescription
blank.
Pre-Printed Information
According to CFR (Code of Federal
Regulations) 1306.05, all prescriptions for
controlled substances shall be dated as of, and
signed on, the day when issued and shall bear
the full name and address of the patient, the
drug name, strength, dosage form, quantity pre-scribed,
directions for use and the name, address,
and registration (DEA) number of the practi-tioner.
The prescription may be prepared by
the secretary or agent for the signature of a
practitioner, but the prescribing practitioner
is responsible in case the prescription does
not conform in all essential respects to the
law and regulations. A corresponding liabil-ity
rests upon the pharmacist who fills a pre-scription
not prepared in the form pre-scribed
by these regulations.
NC General Statute 106-134.1(a) (4) a,
reads, “. . . written prescription must bear
the printed or stamped name, address,
telephone number, and DEA number of
the practitioner in addition to
his legal signature.” This NC
statute requires the referenced
information be on a prescription
blank whether the prescribed
drug is a controlled substance or
non-controlled substance (leg-end
drug). However, if you are
a physician, physician’s assistant,
or nurse practitioner who does
not have a DEA registration
number, then you are not per-mitted
to prescribe controlled substance
medications, only legend drugs, and, obvi-ously,
you are not required to put a DEA
number on your prescription blanks.
In addition to the federal and state regula-tions
noted above, nurse practitioners are
required by North Carolina Medical Board
rules to record the prescribing number
assigned to them by the medical board and
the name of their supervising physician(s)
on each prescription blank. Physician assis-tants
are required by similar Medical Board
rules to record their license number and the
responsible supervising physician’s (primary
or back-up) name and telephone
number.
Having sited these CFR and NC
General Statute/Rule references,
you may ask what all this means.
First, every prescription blank must
contain simple, basic information:
name, address, telephone number,
and DEA number of the prescrib-ing
physician or physician extender.
It is this basic information, either
missing or in error, that is causing
many to have second thoughts and questions
about physicians’ prescription blanks.
Handwriting
When you couple that lack of required
information on a prescription blank with the
serious and not uncommon problem of
scrawled and even indecipherable physician
handwriting, you have created extra work
for the dispensing pharmacist, who may
have to delay delivery of medication(s) to a
patient. The pharmacist cannot dispense
medication to a patient until he or she has
confirmed who the prescribing physician is
and/or what medication/dosage was intend-ed
to be dispensed. Whatever the source of
the pharmacist’s dilemma, it is one fraught
with the potential for error.
Pharmacists have called the Board’s office
to report they were unable to fill
a specific prescription because
they could not read the physi-cian’s
signature and the pre-scription
blank did not have the
physician’s name pre-printed on
it.
Two examples of prescription
blanks not having physicians’
names pre-printed on them are
those found in hospital emer-gency
rooms or county health
departments. When the pharmacist receives
such a prescription and the physician’s signa-ture
is no more than a squiggly line, he or
she must make an attempt to call the clin-ic/
hospital to find out who wrote the pre-scription.
Depending on the day and time
of the pharmacist’s call, it may prove impos-sible
to speak with the physician who wrote
the prescription. In fact, the pharmacist’s
call may not be answered at all, particularly
if the patient brings the prescription to the
pharmacy after the clinic has closed for the
day. If unable to confirm who authorized
the prescription, the pharmacist may be left
with only one option: tell the
patient to return the next day
after the pharmacist has had an
opportunity to speak with the
physician. Such delay is an
inconvenience to patients and
may be harmful to them.
A more serious problem
exists if the pharmacist is left to
decipher the drug name,
strength, quantity, and direction
for use when these are handwrit-ten
by the physician in an indecipherable
scrawl. The Institute of Medicine reported
last year that a range of medical errors,
including written miscommunication
between physicians and other health care
professionals, may claim as many as 98,000
lives a year. It has been suggested that doc-tors’
handwriting can be a contributing fac-tor.
Lawsuits have been filed and successfully
litigated regarding injury and death due to
illegible handwriting. In late 1999, a Texas
jury heard a case concerning the accidental
death of a 42 year-old man who suffered a
heart attack after receiving the wrong med-ication.
The physician intended the patient
to be given Isordil, 80mgs per day for heart
pain; instead, the pharmacist misread the
doctor’s handwriting and dispensed Plendil,
80mgs per day, a drug to treat high blood
pressure. Maximum recommended daily
dose of that drug is 10mgs. The victim’s
family was awarded several hundred thou-sand
dollars.
Conclusion
So, if you want to avoid getting telephone
calls at all hours of the day and night from
pharmacists stumped by your handwritten
prescriptions, and, even more bothersome, if
you want to avoid that hard bench at the
courthouse courtesy of litigation, include all
the required pre-printed information on
your prescription blanks and be sure others
can read and decipher your handwriting.
When pharmacists do call to inquire about
patients’ prescriptions, please answer their
questions in a professional manner.
Maintaining open communication and rap-port
is the best medicine for the patient.
“Lawsuits have
been filed and
successfully liti-gated
regard-ing
injury and
death due to
illegible hand-writing”
“Pharmacists have
called the Board’s
office to report they
were unable to fill
a specific prescrip-tion
because they
could not read the
physician’s signa-ture”
No. 3 2000 9
Mr Work
Prescriptions and New Technologies
Various new methods of transmitting pre-scriptions
have generated questions from
physicians and other prescribers. Systems
now exist for generating prescriptions
through a word processor or computer and
this is just one example of new technology
begetting more questions. Pharmacy Board
rules provide for electronic (.1814) and fax
(.1807) transmission of prescriptions, with
several specific requirements.
Perhaps the most significant technology
limitation on prescribing pertains to con-trolled
substances. Federal regulations gen-erally
prohibit the fax transmission of pre-scriptions
for Schedule II drugs such as mor-phine
or Dilaudid®, except for specific situ-ations
such as hospice patients or patients in
long-term care facilities.
At the state level, the responsible state
agency with jurisdiction over controlled sub-stances
is the Controlled Substances Drug
Regulatory Branch of the Division of Mental
Health, Developmental Disabilities and
Substance Abuse Services. It is their posi-tion
that prescriptions for controlled sub-stances
can be individually generated by a
computer and would be legal provided the
prescriber manually signs the document.
It is worth noting that only 10 to 15 per-cent
of prescriptions are for controlled sub-stances,
so the great bulk of prescriber’s
orders are easily transmitted either by fax or
electronically in the same way as e-mail. By
way of comment, the Pharmacy Board staff
recommends fax transmission rather than
telephone orders on both new prescriptions
and refill authorizations for several good rea-sons.
One is that there is a written record of
what was prescribed or authorized, which
promotes accountability. Another reason is
that pronunciation issues (Xanax® vs
Zantac®) are avoided and the
time/date/source tagline can verify validity.
From the North Carolina Board of Pharmacy
Focus on Prescriptions
David R. Work, Executive Director, North Carolina Board of Pharmacy
Although bogus prescriptions can occur in
any system, we have seen many more forg-eries
with phony telephone orders or stolen
prescription pads. This is a good reminder
for prescribers to keep closer track of their
unused prescription documents.
The status of a particular drug can be
determined in two ways. First, and easiest,
is to make a list of the drugs commonly used
in your practice and ask your local pharma-cist
which can be ordered electronically or by
telephone or fax and which must be ordered
in writing. Or each drug can be found in a
standard reference such as Facts and
Comparisons or The American Drug Index,
both available from their publisher at
800.223-0554. The Physician’s Desk
Reference is useless for this task because it is
an incomplete reference of some, but not all,
brand name drugs, and generics are not
included.
Drug Substitution
Physicians who are concerned about drug
substitution need to be aware of the func-tioning
of the state’s Product Selection (sub-stitution)
Law. The current statute allows
the substitution of a generically equivalent
drug for brand name drugs unless the pre-scriber
overrides the pharmacist in one of
several ways. The first method is by using a
two line prescription form that is prescribed
by statute (one line with “Dispense As
Written” on the lower right-hand side of the
prescription and one line with “Product
Selection Permitted” on the lower left-hand
side). Another is to write the words
“Dispense As Written” or “DAW” on the
face of the prescription. If the prescription
document is in another format, such as a one
line form, or if the prescriber fails to write
“DAW” on the face of the prescription, then
the pharmacist is able to use the generic ver-sion
of the drug.
NTI Drugs
The Product Selection Law also incorpo-rates
the Narrow Therapeutic Index (NTI)
concept into state law. This specific part of
the statute states that drugs that require
blood monitoring, or have formulation-dependent
variability, or whose toxic dose is
less than twice the effective dose must be
refilled with the same manufacturer’s prod-uct
used on the prior filling. If the pharma-cist,
or health plan, wants to change to a dif-ferent
manufacturer, then the pharmacist
must get the documented consent of both
the prescriber and the patient prior to
switching products. Drugs currently on the
NTI list are listed below.
carbamazepine (all dosage forms)
[Tegretol®, various others]
cyclosporine (all oral dosage forms)
digoxin (all dosage forms) [Lanoxin®]
ethosuximide (all oral dosage forms)
levothyroxine sodium tablets
[Levothroid®, Levoxyl®, Synthroid®,
various others]
lithium (all oral dosage forms, all salts)
[Cibalith®]
phenytoin (all oral dosage forms, all
salts) [Dilantin®]
procainamide hydrochloride (all oral
dosage forms)
theophylline (all oral dosage forms, all
salts) [Elixophyllin®, Slo-Phyllin®, Slo-
Bid Gyrocaps®, Theochron®, Theo-
Dur®, Theo-24®, Uniphyl®]
warfarin sodium tablets [BMS
Warfarin®, Coumadin®, Warfarin®]
Printed Forms
For many years, state statute has required
that all written prescriptions must bear the
printed name, address, telephone number,
and DEA number of the prescriber. This
exists primarily for a public health reason,
which is to provide pharmacists with a name
and telephone number to contact in case
questions about the prescription arise. The
most significant instance when this does
happen is when someone goes to a teaching
medical center for diagnosis and then brings
prescriptions back to his or her home com-munity.
It is not unusual for the documents
to be clearly written until the prescriber’s
name appears at the bottom with a scribble
or a swoosh that doesn’t give the pharmacist
any reliable reference in case questions exist
about dosage or potential drug interactions.
The presence of a printed name and tele-phone
number makes it possible for the
pharmacist to resolve any questions that
might arise.
Conclusion
If you have any questions about these or
other pharmaceutical matters that might
involve the Board of Pharmacy, we suggest
you review the Board’s Web page at
www.ncbop.org, scrolling to Frequently Asked
continued on page 10
10 NCMB Forum
Treating Bias
Researchers have no evidence that
American physicians withhold medical care
from minority and poor patients out of some
type of bias. But there is no end of evidence
that minorities and the poor routinely
receive inferior care, with the obvious result
of shortened lives or chronic illnesses that
mar their quality of life. That is intolerable.
The latest report pointing to racial and
socioeconomic disparities in medical treat-ment
comes from close by. Dr Kevin
Schulman, a Duke University internist, co-authored
a study that found a pattern in
which hospitals sometimes fail to recom-mend
simple, inexpensive therapies such as
aspirin to poor or African-American heart
attack victims upon their discharge from
hospitals. The study, which involved nearly
170,000 Medicare patients, was recently
published in a medical journal.
The gap in quality of care wasn’t as wide
as a chasm. But it was marked, and in real
numbers affects thousands of people. Other
studies also have shown that the poor,
Hispanics and blacks of all income levels
tend to be treated differently than their
white or more affluent counterparts for the
same illnesses.
Schulman thinks the way hospitals work,
especially ones with high loads of poor
patients, is to blame. If that is so, hospitals
could fix some shortcomings by, for exam-ple,
handing out written instructions to
patients who suffer from the same malady.
Still, Congress (or the states) needs to pass
legislation, already introduced in the U.S.
House and Senate, that would require med-ical
students to be trained about cultural dif-ferences.
Bias, whether knowing or inadver-tent,
has no place within the healing art.
__________
Editorial reprinted with permission from The
News & Observer of Raleigh, North Carolina,
8/15/2000. continued on page 11
Focus on Prescriptions
continued from page 9
Questions or New Developments. There is
also a section on Drug Law that some may
find interesting. Another good source of
information is the USP and their Web site at
www.usp.org. They have a program involving
medication error reporting and prevention
that has several specific recommendations,
including the electronic transmission of pre-scriptions
in lieu of handwritten documents.
On their Web site, click on Practitioner
Reporting, the National Coordinating
Council on Medication Error Reporting and
Prevention (NCCMERP), and then
Council Recommendations.
A Brief Guide to Continuing Medical
Education Requirements for Physicians
in North Carolina
A continuing medical education (CME)
rule for physician licensees of the North
Carolina Medical Board became official in
July 2000. Adoption of the rule was the
result of a legislative mandate that can be
found in NC General Statutes 90-14 (a)(15).
The rule itself appears at the end of this
Guide and may be found in the NC
Administrative Code at Title 21, Chapter 32,
North Carolina Medical Board, Subchapter
32R-Continuing Medical Education (CME)
Requirements.
When Does the Rule Become
Effective?
It becomes effective in 2001. You will
need to obtain and document for your files
the required practice-relevant CME starting
with your birthday on or after January 1,
2001. You will be asked to report your
total hours of applicable relevant CME
each year on your annual license registra-tion
form, but you will have three (3)
years to meet the requirement. Thus, the
first licensees required to have at least the
150 hour total (as defined in the rule) will be
those with birthdays in January who register
in 2004 and have been licensed for at least
three years. Others will have to meet the full
requirement by the month in which they
register in 2004 (if they have been licensed
for at least three years at that time).
Simply put, for a physician licensed
before January 1, 2001, the three-year
CME cycle begins on his or her birthday
in 2001. For a physician licensed during
or after 2001, the CME cycle begins on
his or her first birthday following the
granting of the license.(Some examples of
individual situations are provided below in
the section How Does the Three-Year Cycle
Work?)
How Can I Prepare for Reporting
and Documenting My CME?
We strongly recommend you set up a sys-tem
now for demonstrating compliance.
This will be easier than waiting until the last
minute and will help ensure the system is as
comfortable as possible for you in your cir-cumstances.
As you know, we have been
asking for CME reports on annual registra-tion
forms for some time, even though there
has not been a CME requirement in place for
physicians. Therefore, thinking about CME
reporting in the context of annual registra-tion
should be natural. You will find a CME
report segment on the registration form in
2001, as usual, with only some changes in
wording to remind you that CME is now
required and that you should maintain doc-umentation
of CME for six years. (And if
you hold licenses in other states requiring
CME, you should compare our requirement
with theirs to be sure your documentation
will be appropriate for each.)
Documentation for North Carolina
Credit 1 CME (provider-initiated) can be
as simple as keeping a dated record of your
attendance at or participation in relevant
CME programs conducted by ACCME or
AOA accredited institutions, along with a
file of receipts or certificates verifying the
information recorded. For North Carolina
Credit 2 CME (physician-initiated), it can
be as simple as keeping a list of relevant
CME activities initiated by yourself and not-ing
the nature of the activity, the date, and
the hours earned.
How Does the Three-Year Cycle
Work?
The Board’s new CME requirement is
based on a three-year cycle, a time period
similar to that used by a number of states
and medical organizations with CME
requirements or programs. However,
because the North Carolina system is keyed
to your birthday and because of the need to
report during your birth month as part of
our annual registration process, our system
will differ from some others. It may be use-ful
to give examples to demonstrate some of
the permutations. Below are some cases we
hope will clarify the process for those of you
who have questions about how the system
will work as reporting begins. Each example
assumes the hours mentioned represent rele-vant
CME and that the 150 hour minimum
includes at least the 60 hours of NC Credit
1 CME (provider-initiated) required by the
rule. Remember, the three-year CME
cycle will vary for each licensee depending
on his or her birth month and date of
licensing.
Physician A: Licensed in NC during 2000
or before, birthday in January. . .
The licensee must meet the 150
hour requirement by January registra-tion,
2004. Reports 0 hours in January
2001 (cycle opens, counting begins at
this point). Has several options. (1)
Can get 150 hours in March 2001,
report 150 hours at next registration in
January, 2002, report 0 hours in
January 2003 and 2004 respectively.
No. 3 2000 11
Brief Guide to Education
continued from page 10
That will meet the CME requirement as
of 2004. Then in 2004, the licensee
starts over, working for the 150 hour
total that will be needed by 2007. (2)
As an option, the licensee can get 150
hours in November 2003, reporting 0
in January 2002 and January 2003, and
reporting 150 in January 2004. (3)
Finally, the licensee can break it up,
reporting combinations such as 50
hours of CME in January 2002, January
2003, and January 2004. In any case,
the licensee starts with a clean slate in
January 2004, as the cycle starts over.
Physician B: Licensed in February 2001,
birthday in January. . .
Does not have to start counting and
reporting toward the 150 hours until
January registration, 2002. Does not
need to have all 150 hours until January
2005.
Physician C: Licensed in October 2002,
birthday in November. . .
Receives a registration form in
November 2002. Does not have to
report any CME on his November
2002 registration form, but has to start
counting and documenting CME
beginning in November 2002. Has to
have 150 hours by November 2005.
Physician D: February birthday, gets 150
hours of CME between February 1, 2001,
and February 1, 2002. . .
Meets the requirement early.
Reports the 150 hours on February
2002 registration, does not need to
report any CME in February 2003 or
2004. However, licensee is diligent
about CME and gets and reports 150
hours in 2003 and 2004 respectively.
Easily meets the requirement for 150
hours for registration in 2004: only had
to get 150 hours but reports 450 hours
cumulatively over the three years since
his registration in February 2001.
Cannot carry hours over to the next
cycle, however. Has to start with a
clean slate with registration in 2004 and
accumulate 150 new hours before
February 2007.
Physician F: Does not practice in North
Carolina but keeps license active, does not
set foot in NC during entire cycle. . .
Location does not matter, has to
meet requirement.
Physician G: Can only document 50 hours
at the end of 3 years, should have met
requirement. . .
Following full due process, includ-ing
notice and hearing, has exposure to
a public disciplinary order. The Board’s
action may or may not be considered by
another state as a bar to licensure, and it
may or may not affect hospital privi-leges
or eligibility for reimbursement by
Medicare or Medicaid. Whatever the
case, it is not worth it to the licensee.
Physician H: Has specialty board certifica-tion
with a board that has CME require-ments
that meet or exceed the requirements
of the NCMB; specialty board maintains
documentation. . .
The licensee’s CME must comply
with the NCMB rule in relation to cred-it
type, quantity, and time period, and
the licensee must report his or her CME
on the annual registration form. If the
licensee is one of those randomly select-ed
for inspection for CME compliance,
the documentation provided to the spe-cialty
board can be used but it must
meet the NCMB’s requirements. The
fact of certification itself is not docu-mentation.
Physician I: Has an inactive license, either
because he or she requested it or because of
failure to reregister. . .
Is not registered and, therefore, does
not have to comply with the CME
requirement unless or until license is
reactivated. (Those who hold inactive
licenses may not practice medicine in
North Carolina.)
How Does the Requirement Apply
to Residents in Training
The rule makes clear that licensees who
are residents enrolled in ACGME or AOA
accredited graduate medical education pro-grams
are exempt from the requirement.
What Is “Relevant” CME?
The idea of relevance is an essential part of
North Carolina’s CME requirement and sets
it apart from such requirements in many
other states. The CME used to satisfy the
North Carolina requirement, at either
credit level, must relate to your actual
practice of medicine. It seems obvious that
CME, to be meaningful, should be focused
on maintaining and enhancing your ability
to provide care for your patients or for those
patients affected by your professional ser-vices.
When asking yourself if the courses or
studies you want to pursue are relevant,
answer this simple question: Do they have a
direct impact on my care of my patients? If
you can make the case that the word and the
spirit of the requirement have been met,
there should be no problem.
Of course, some physicians do not treat
patients or provide professional services
related to the treatment of patients. Their
tasks are purely administrative or otherwise
have no direct effect on patients. CME for
them may be management related or institu-tional
in nature. However, if their work
involves review of medical records, signifi-cant
CME directed to patient care issues
would be called for. And if they see or pro-vide
professional services for patients on a
limited schedule, CME directed to their par-ticular
practice should be a significant part of
their CME effort. Again, they should be
able to make the case that the word and the
spirit of the CME requirement have been
met.
How Do I Compute My Various
CME Activities?
In the case of NC Credit 1 CME
(provider-initiated), ACCME and AOA
accredited institutions note the credit-hour
value of such programs in their printed
materials and announcements and on the
attendance/participation certificates they
give. Simply record these in keeping with
the number awarded by the institution.
NC Credit 2 CME (physician-initiat-ed)
presents a different situation. Some of
the twelve items listed do not fit a neat hour-by-
hour scheme, most do. Study, consulta-tions,
outcomes research, mentoring, teach-ing,
creation of generic patient care materi-als,
and participation in M&M conferences
and journal clubs can be measured by the
clock, though activities such as teaching
should include the time required for prepa-ration.
Competency assessment may involve
a variety of activities, all of which should be
included in the calculation of time. Passing
a specialty board examination can be count-ed
as the maximum three-year NC Credit 2
CME allowance. (Of the 150 hours of CME
credit required in three years, at least 60
must be NC Credit 1 CME. All the rest, up
to 90, may be NC Credit 2 CME.)
Can I Roll Excess CME Hours Over
to the Next Cycle?
No. The CME hours earned within a
three-year cycle can be used only to fulfill the
requirements for that cycle, which cannot be
extended or shortened.
Can I Use the PRA or Similar
Awards for Reporting?
Yes and no. You can use the records you
kept and reported to the AMA or other
organizations to earn their CME awards for
documentation, but you must highlight and
count only those CME experiences that
qualify as relevant, that meet the North
Carolina CME definitions, and that fit with-in
North Carolina’s three-year cycle.
Therefore, because of the need to demon-strate
relevance, to fit the CME defini-tions,
and to count only those hours
earned within your North Carolina three-year
cycle, the Physicians Recognition
Award and similar awards, taken by
continued on page 12
12 NCMB Forum
Brief Guide to Education
continued from page 11
themselves, cannot be accepted as docu-mentation.
How Will the Requirement Be
Enforced?
A random sample of registrants will be
asked to provide documentation of their
reported CME at the end of their reporting
cycles. Also, those who are called before the
Board for informal interviews or for formal
action will be asked to provide documenta-tion
of their reported CME. The Board
will take appropriate action against those
who fail to report completing the CME
requirement within a cycle and those who
cannot satisfactorily document their
CME reports. Board action will vary
depending on the particular circumstances.
What Do I Do If I Have More
Questions?
If you have a question not answered here,
e-mail us at info@ncmedboard.org. Or:
Fax: 919.326-1130.
Telephone: 919.326-1100.
Write: North Carolina Medical Board
Attention Registration, PO Box 20007
Raleigh, NC 27619.
CME RULE
Title 21 Chapter 32 North Carolina
Medical Board
Subchapter 32R - Continuing
Medical Education (CME)
Requirements
.0101 CONTINUING MEDICAL EDU-CATION
(CME) REQUIRED
(a) CME is defined as knowledge and
skills generally recognized and accepted by
the profession as within the basic medical
sciences, the discipline of clinical medicine,
and the provision of healthcare to the public.
CME should maintain, develop, or improve
the physician’s knowledge, skills, profession-al
performance and relationships which
physicians use to provide services for their
patients, their practice, the public, or the
profession.
(b) Each person licensed to practice med-icine
in the State of North Carolina shall
complete no less than 150 hours of practice
relevant CME every three years in order to
enhance current medical competence, per-formance
or patient care outcome. At least
60 hours shall be in the educational
provider-initiated category as defined in
Rule .0102 of this Subchapter. The remain-ing
hours, if any, shall be in the physician-initiated
category as defined in Rule .0102
of this Subchapter.
(c) The three year period described in
paragraph (b) above shall run from the
physician’s birthday beginning in the year
2001 or the first birthday following initial
licensure.
.0102 APPROVED CATEGORIES OF
CME
The following are the approved categories
of CME
(1) Educational Provider-Initiated CME:
All education offered by institutions
or organizations accredited by the
Accreditation Council on Contin-uing
Medical Education (ACCME)
and reciprocating organizations or
American Osteopathic Association
(AOA)
(a) Formal courses
(b) Scientific/clinical presenta-tions,
or publications;
(c) Enduring Material
(Audio-Video)
(d) Skill development
(2) Physician-Initiated CME:
(a) Practice based self-study
(b) Colleague Consultations
(c) Office-based outcomes
research
(d) Study initiated by
patient inquiries
(e) Study of community health
problems
(f) Successful Specialty Board
Exam for certification or recer-tification
(g) Teaching (professional,
patient/public health)
(h) Mentoring
(i) Morbidity and Mortality
(M&M) conference
(j) Journal clubs
(k) Creation of generic patient
care pathways and guidelines
(l) Competency Assessment
.0103 EXCEPTIONS
A licensee currently enrolled in an AOA or
Graduate Medical Education (ACGME)
accredited graduate medical education pro-gram
is exempt from the requirements of
Rule .0101 of this Section.
.0104 REPORTING
At the time of annual registration imme-diately
following the CME reporting period,
each Licensee shall report on the Board’s
annual registration form the number of
hours of practice-relevant CME obtained in
compliance with section .0101 of this
Subchapter. Records documenting CME
hours must be documented by categories for
six consecutive years and may be inspected
by the Board or its agents.
A special file was also to be added to the
Board Action Section of the program listing
all physicians whose licenses have been
declared “inactive.”
To all the staff members at the NCMB
who supported the initial concept of the
DataLink program, along with the hospitals
that have supported and purchased the soft-ware,
we, as medical staff professionals,
would like to say “thank you.” DataLink is
a very important part of the credentialing
process at most North Carolina hospitals. In
fact, it would be wonderful if, somehow, the
same licensing data, provided by their licens-ing
agencies, could be downloaded into
DataLink for the dentists, podiatrists, and
optometrists. Maybe this could be a joint
venture.
Hospitals Need DataLink
To those hospitals that do not have
DataLink, we would say that you are miss-ing
out on a great credentialing tool! As
more and more hospitals are linked to this
program, JCAHO surveyors will expect to
see the presence of this software during your
survey process. With the new regulations
for licensing, if your license information is
not computerized, you will have a creden-tialing
nightmare.
Area hospitals have found access to
DataLink to be very reliable and the staff
at the NCMB have
always responded in a
prompt and courteous
way. The DataLink is
considered a primary
source verification,
and JCAHO surveyors
have been impressed
with DataLink and the
fact that it offers 24-hour access, seven days
a week. DataLink is also good for verifying
licenses of non-staff physicians that order
non-invasive tests or labs or refer a patient to
one of your outpatient services.
NCAMSS would like to take this oppor-tunity
to say “thank you” to the staff of the
NCMB for their help in providing us with
DataLink, and for including members of our
association as participants in meetings to dis-cuss
updates of the software.
“DataLink is a
very important
part of the cre-dentialing
process at most
North Carolina
hospitals”
DataLink
continued from page 7
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina Medical Board
No. 3 2000 13
at 11:00 a.m. My mother explained that
the only other problem she could tell was
that he was “a little clammy.”
My father had not been to a doctor in
over 20 years. He is a heavy smoker, and
he is mildly overweight. Several possibil-ities
of what could be wrong crossed my
mind: cholelithiasis or cholecystitis,
appendicitis, pancreatitis, early bowel
obstruction, a GI virus, or kidney stones.
I just was not sure. I finally asked my
mother to go to the den, to have my
father lie down on the couch, and to get
on the phone in the den. When she got
back on the line, I explained to her how to
divide the abdomen into four quadrants,
with the belly button being the center
point. I told her to feel the upper right
side and push down gently. She did that,
and it did not cause any pain. Then she
moved down to the right lower area and
did the same. Again, this was not uncom-fortable.
She then went to the left lower
quadrant. This area was not tender either,
but as she moved her hand up she said,
“Charlie, what is this hard lump?” He
said he had not noticed anything there. I
asked the size and location, and she told
me that it was like a baseball to the left of
his belly button. She kept feeling it, and
then came the dreaded words: “Laurie, it
feels like it is thumping... like it has a
heartbeat.” My heart sank! I knew at this
point exactly what he had without a
doubt, a large abdominal aortic aneurysm
that was obviously leaking and causing the
pain in his back and abdomen. I tried to
remain calm so I would not scare my
mom, but I think she knew it was bad. I
told her to take him to the closest hospital
right away. I had her write on a piece of
paper “pulsatile abdominal mass, left of
umbilicus” and give it to whomever she
saw first when they got there. Because it
would be faster and my father was still
talking and able to move around, I told
her to drive him to the hospital rather
than call and wait for an ambulance.
When they arrived at the emergency
room, my mom handed the paper to the
nurse. From then on, things moved
incredibly fast. The CT, performed even
before registration, revealed a 9.2 cm leak-ing
abdominal aortic aneurysm. My
father asked to speak to my mother, and a
pastor came in to see him, because the sur-geon
gave a rather grim prognosis. He
was in the operating room within 30 min-utes.
He survived the operation, but he
required reintubation 2 days postopera-tively
and required a total 10 units of
blood. He was discharged 14 days post-operatively
and has recovered completely.
It is difficult to write about this even
now. I still get tearful when I think about
how close he came to dying. I was so
close to telling my mother that night to
just have him lie down for a while and see
if he felt better. But the fact that my dad
was complaining of pain, I knew it had to
be more than just a “flu.” My mother did
all the right things to help me determine
that it was worse than either of us could
have guessed. The pieces, for whatever
reason, fell together and allowed my dad
to pull through what is generally a fatal
situation. We are truly fortunate, and it
really is a miracle.
Others have documented the contribu-tions
of physician assistants with respect and
admiration. Miller et al* demonstrated that
physician assistants can be an excellent alter-native
for a trauma center that does not have
surgical residents. In a three-year study of
their trauma experience, these trauma sur-geons
reported that physician assistants
saved them 4 to 5 hours per day, reduced
patient transfer time from the emergency
department, and reduced lengths of stay.
Perhaps the best indicator of the value of
this new profession is the recent election of
Mr Wayne W. VonSeggen, a practicing
physician assistant for more than 20 years, to
the presidency of the North Carolina
Medical Board. This was not a political
process. Mr VonSeggen served as president
of the North Carolina Academy of Physician
Assistants from 1983 to 1984 and held posi-tions
on numerous other committees over
the years. Mr VonSeggen was chosen unan-imously
by a board that is two-thirds physi-cians
– physicians recognizing his adminis-trative
skill, his integrity, and his thoughtful
judgment.
In the reviews of the surgical advances of
the last millennium, we saw many citations
on cardiac surgery, transplantation, minimal-ly
invasive techniques, and breakthroughs in
monitoring. We would like to add another,
often overlooked topic, the development of
physician assistants and nurse practitioners.
We delight in their success and wish them
well for at least another century.
.........................
* Miller W, Riehl E, Napier M, Barber K,
Dabideen H. Use of physician assistant as
surgery/trauma house staff at an American
College of Surgeons-verified level II trauma cen-ter.
J Trauma 1998; 44:372-376.
_________________
Reprinted with permission from Current Surgery,
Vol. 57, No. 2, March/April 2000.
Surgeons rarely
practice alone. Folks
may think of us as
Lone Rangers, but
we do our best work
when we have a col-league
across the
table. I learned this
on my first day on
the clinical wards
when my older sis-ter,
an experienced
nurse, told me the
secret of survival, “Stay on the good side of
the nurses.”
The advice is still sound, but today, it
should be expanded to include a newer
group of professionals misnamed “physician
assistants.” They do more than assist; they
serve as our ears and eyes, our hands, and
often our consciences. They are true col-leagues,
and we are fortunate to have them
at our sides.
In surgery, we teach with stories. Let me,
therefore, share a story with you as told by
Ms Laurie Driscoll, an excellent physician
assistant working in our department here at
the Brody School of Medicine at East
Carolina University.
I had just walked in the door from
work, and the phone was ringing. It was
my mother. She called because my father
had been having vague abdominal and
lower back pain since about noon. It was
now 6:00 p.m., and he was not any better.
All of this was very unusual because my
father has never really been sick, and he
rarely complains about aches and pains.
Earlier that day, he had gone to his reg-ular
Wednesday morning card game in
Fort Pierce, a small town in Florida about
30 minutes from his home. He began
having vague, diffuse abdominal cramp-ing
around 1:30 p.m.. He played cards
until about 4:30 p.m. and then came
home. He explained to my mother the
pains he was experiencing, and my moth-er
gave him Gas-X. It provided no relief.
In addition to his abdominal pain, he also
began to have lower back pain, and he
complained of having to belch a lot.
After my mother had relayed the entire
story, I began asking her some routine
questions. “Was there any nausea or vom-iting?”
“None.” “Had he experienced any
diarrhea?” “No.” “Had he had a normal
bowel movement that morning?” “Yes.”
“Was there any pain or burning upon uri-nation?”
“No.” “Did he have an
appetite?” “None,” and he had last eaten
Dr Pories
The Physician Assistant
Walter J. Pories, MD, Secretary/Treasurer, NCMB
with Laurie Ann Driscoll, PA-C
14 NCMB Forum
LETTERS TO THE EDITOR
Legislation Is the Best
Solution to Records
Problem
To the Editor: Two articles in the Forum
recently struck an especially resonant chord,
due not only to their content but also their
physical proximity by appearing in the same
issue (Roufail, WM: HMOs: Have We
Painted Ourselves into a Corner? and Watry,
AW: Patient Access to Medical Records,
both in the Forum, 2000;Vol. V, No. 2).
While agreeing wholeheartedly with the for-mer,
the latter produced serious misgivings.
When decrying the death of traditional
private medical practice at the hands of “big
business,” HMOs, and the federal govern-ment,
Dr Roufail tellingly places the blame
for Mr Watry’s problem regarding patients’
decreased access to their medical records
exactly where it belongs: with the physi-cians,
patients, captains of business, voters,
and politicians who either built today’s mis-managed
care juggernaut, cheered it on, or
simply stood idly by while it grew to mono-lithic
proportions. Mr Watry’s concerns are
certainly well-founded, but some of his solu-tions
seem less than optimal considering the
climate in which most contemporary physi-cians
must work.
Mr Watry warns against legislation placing
a dollar value on medical records, yet here in
West Virginia the legislature’s appraisal,
years ago, of not more than $1.00/page for
copies of medical records solved many more
problems than it created. Interestingly, and
probably not coincidentally, this is the same
value the market had placed on copies of
legal documents, specifically copies of depo-sitions
in medical malpractice litigations.
Having a statutorily defined value makes
physicians’ patient records simply another
product in the medical business inventory,
another order to be filled and shipped,
another source of cash-flow. Certainly, cus-tomers
are always entitled to purchase prod-ucts
through an open market at a profit to
the provider.
As far as his lament about loss of continu-ity
in patient care, Mr Watry surely recog-nizes
that it was literally thrown out with the
baby’s bathwater when medical care mega-corporations
began employing “independent
primary care providers” such as nurse practi-tioners
and midwives, physician assistants,
and “doc-in-the-box” physicians who were
rotated daily through a pool of storefront
clinics in widely-spread locations. Patients
moving down the high-efficiency, maximum
production assembly lines of these medical
care factories already, in Mr Watry’s words,
“are left in the lurch, not knowing who is
going to treat them next, who has access to
their records, and whether or not their
records are in a secure location; and they are
left without appropriate mechanisms for get-ting
these records to a new health care
provider in order to provide continuity of
care.” When he refers to the way things used
to be “[i]n days past,” that’s exactly what
they are: past, gone, over, history. We now
practice within a new paradigm.
Legislation is certainly the best alternative
solution to any problems with patient access
to medical records, realizing that statutory
relief ideally is intended to establish only a
minimum legal standard that should be fair
to all parties involved. Such legislation
should first of all relieve private physicians of
eternal responsibility for record maintenance
by defining a statute of limitations after
which, if there were no subsequent entries,
any records, financial or medical, could be
safely destroyed without fear of litigation or
prosecution.
Secondly, responsibility for medical
records should rest with the legally and con-tractually
defined custodian, not necessarily
the attending physician. This is already the
case with the records of hospitals and corpo-rate
care entities, so there’s no plausible
argument for maintaining this onus indefi-nitely
on private physicians who sell their
practices or retire, nor on their estates and
survivors when they die. The office records
are simply another asset purchased in the
deal or listed in the estate and should carry
no greater responsibility for their mainte-nance.
While legislation presents the imposition
of a minimum standard, it is obvious that
almost all physicians in private practice will
operate their businesses to a higher standard
out of respect for traditional medical ethics
and responsibilities. Lawyers, government
administrators, and insurance companies
should be charged the maximum allowable
by law for their requested records, yet
patient and collegial requests will almost
always be honored pro bono. I personally still
maintain all records, both financial and med-ical,
of every visit of every patient ever seen
in my private practice. Although sometimes
involving repeated requests and voluminous
documents, no patient has ever been directly
charged for copying and mailing her records.
Over the years, many colleagues in private
practice have either moved, retired, or died,
and almost all their patients have been noti-fied
by newspaper advertisements or direct
mail regarding where their records would be
transferred (usually another local physician’s
office) or a date until which records would
be transferred at no charge upon patient
request to a physician designated by the
patient, afterward allowing destruction of
untransferred originals.
While there is never an ideal solution to
any problem that will completely satisfy all
parties, patients who opt to continue their
care within the traditional private practice of
medicine will have fewer complaints and
these can be easily addressed through state
medical licensing boards and local medical
societies existing mechanisms. For the rest,
legislation already insures fair treatment to
all participants in various business transac-tions
by clearly defining rights and responsi-bilities
of each without imposing unreason-able
burdens upon any. It will do the same
in the medical marketplace.
William D. Daniel, MD, FACOG
Executive Director, American Society
of Forensic Obstetricians and
Gynecologists, Buckhannon, WV
Response
Thank you for your letter. We appreciate your
insight and commentary. I have this skepticism
(perhaps unfounded) that when issues like this
are brought to a legislative agenda there is expo-sure
to getting more than you bargained for.
For example, no one would reasonably argue
that our government should not have open
records and citizens should not have access to
them. I am aware of one state, however, that
mandates open records must be provided in three
working days. Thus, the response to an open
records request becomes a higher priority to the
agency than its other legislative mandate (med-ical
licensure) that has no time limits imposed
on how quickly someone is licensed or disciplined.
Your points provide balance to my argument
and I thank you for them.
Andrew W. Watry, Executive Director
North Carolina Medical Board
And More on
Medical Records
To the Editor: The article Patient Access to
Medical Records written by the Board’s
executive director, Andrew W. Watry, MPA,
continued on page 15
No. 3 2000 15
in No. 2, 2000, of the Forum, presents the
North Carolina Medical Board’s position
regarding charges for copying and postage
of patient records incorrectly.
Mr Watry states in his article: “Another sit-uation
we see with increasing regularity is
the physician holding records until payment
is made for an unsettled account or for the
copying of the records themselves. This is
contrary to the Board’s position statement
on medical records.” Mr Watry goes on to
say that “maintaining and keeping files is a
cost of doing business, . . . .”
The NCMB Position Statement, as
amended 9/1997, says, “The physician may
charge a reasonable fee for the preparation
and/or the photocopying of the materials.”
This clearly contradicts the notion that copy-ing
and mailing is free to the recipient or “a
cost of doing business” to the practice.
I support the policy given in the 1997
NCMB Position Statement. While there is
little room for debate that maintaining and
keeping files for the purpose of patient care
within the practice has long been universally
accepted as a cost of doing business, the
expense of copying, handling, and postage
of records for transfers has not been univer-sally
accepted. Furthermore, adding to the
long list of documents, forms, and records
that are furnished at “no additional charge”
is beyond the pale. Indeed, many services,
so considered in the past, may now need
reconsideration. Faced with the choice of
allocating scarce personnel and other
resources to the task of preparing and trans-ferring
2/3-year-old medical records or car-ing
for the patients at hand, I have little
doubt how healthcare providers should pri-oritize
tasks. If forced to do otherwise, I fear
the quality of care might be threatened. It
might make more sense to encourage physi-cians,
attorneys, insurance companies,
employers, and the myriad of others request-ing
“All Medical Records” to limit their
requests in both number and scope. Paying
their way would be a step in that direction.
After all, cost shifting is just about a thing of
the past!
G. David Dyer, MD
Wrightsville Beach, NC
Response
Thank you for your letter. The premise of your
argument seems to be that when I refer to
“maintaining and keeping files is a cost of doing
business. . .” I am suggesting that these copying
and mailing costs should be free to the recipient.
I respectfully disagree for two reasons.
Letters to the Editor
continued from page 14
(1) I am not aware of anyone in business who
assumes that a “cost of doing business” should be
free to a recipient. These costs are almost always
passed to customers in one form or another.
There is no free lunch.
(2) You terminated my quote at a place that
takes the sentence out of context. The whole sen-tence
was: “Maintaining and keeping files is a
cost of doing business, and it is recognized that
in many businesses it is acceptable to withhold
services until fees are paid. For the most part,
this is not so in medicine.” This is not advocacy
for furnishing records at no charge. There is a
big difference. I go on in the article to state
options, such as collection agencies. I am trying
to help physicians and their patients avoid a
major quicksand pit when medical records are
held for payment of a fee. Imagine a physician
defending himself or herself in a courtroom for
not sending a mammogram to an oncologist
because a fee had not been paid yet, compromis-ing
continuity of care. How do you think a jury
would rule?
Thank you for your comments. We are at your
service if we may assist you in any way.
Andrew W. Watry, Executive Director
North Carolina Medical Board
Male Victimization
To the Editor: Regarding the Special Topic:
Domestic Violence [by Laura A. Queen]
that you published in the Number 2, 2000,
issue of the Forum, I applaud your intent in
bringing this important issue to print, but I
must point out that the victims of domestic
violence are not always female. In fact, there
have been cases, though rarely reported, of
males/husbands who were victims of vio-lence
perpetrated by women in the house-hold/
wives.
Of all the printed material and conferences
on domestic violence, I have yet to see or
hear any mention of male victims. Though
almost never reported, male victims do exist.
And I think it would serve to generate more
feedback if every presentation on domestic
violence made mention of male victimiza-tion.
Thank you for disseminating this view-point.
Frank Y. Yang, MD, FACS
Pinehurst, NC
Response
We appreciate your comment and the
thoughtful view you bring forward. We hope you
will note Ms Queen’s second article, which
appears in this number of the Forum, titled
Battered Men: Another Story.
The Editor
Vital Information
Required
by the NCMB
When a physician or physi-cian
extender dies or legally changes
name by marriage, divorce, or other
legal means, that information is
vital to the North Carolina Medical
Board to ensure the accuracy and
completeness of its records and to
effectively serve the interests of its
licensees and the public. Copies of
the legal documents relating to
those events are also needed to add
to the appropriate files.
When a licensee dies, a copy
of the death certificate should be
sent to the Board as soon as possi-ble.
When a licensee marries and
thereby changes name, a copy of the
marriage certificate, showing the
name change, should be forwarded
to the Board. In the case of divorce,
if the decree contains the resump-tion
of a maiden or previous name,
copy of the decree should also be
sent to the Board. When a
licensee’s name is changed by any
other legal means, the relevant legal
document(s) should be sent to the
Board.
It is important to note that
without the legal documentation
the necessary changes cannot be
made to the Board’s records, and
that will result in incorrect names
on registration forms, incorrect ver-ifications
of license, and misinfor-mation
should a licensee be
deceased.
This vital information, and
the supporting copies of relevant
documents, should be sent to the
following address: North Carolina
Medical Board, Attention: Ms Ann
Norris, PO Box 20007, Raleigh,
NC 27619.
16 NCMB Forum
education at St Thomas’s Hospital, London,
Cream’s fiancee became ill and her father
discovered she was experiencing complica-tions
of a recently induced abortion per-formed
by person or persons unknown,
assumed to be Cream. A literal “shotgun
wedding” was quickly performed before
Cream’s embarkation, but less than a year
later the newly wed Mrs Cream died follow-ing
a short illness with suspicious symptoms
which were treated with pills mailed by her
husband from London.
During his studies at St Thomas’s, Cream
was exposed to Dr Albert James Bernays,
professor of chemistry and a medical expert
witness for the Crown Prosecutor in a high-profile
trial charging murder by strychnine
poisoning. The case had been difficult to
solve due to the lack of uniformity in British
coroner inquest law, the prestigious British
Medical Journal opining that as a result
many violent deaths by poisoning were
probably going uninvestigated.
Cream also took advanced training in
obstetrics at St. Thomas’s while Lister
sprayed carbolic acid around the operating
rooms at nearby General Lying-In Hospital,
but in 1877 the young Canadian obstetrician
failed his anatomy and physiology entrance
examinations for the Royal College of
Surgeons. The following year, he was
admitted to the Royal Colleges of Physicians
and Surgeons, Edinburgh, with a midwifery
license and in May returned to London,
Ontario, where he opened an obstetrical
practice. Following the death of a patient
from an overdose of chloroform suspected
to have been employed as an anesthetic for
elective abortion (her body was discovered
in the outhouse behind his office), Cream
hastily crossed the border to Chicago and
was licensed by the Illinois State Board of
Health in August 1879, promptly opening a
medical office in the city’s busy red light dis-trict.
Cream had long been known as a woman-izer
and frequent consort of prostitutes, and
it was common knowledge he provided
abortions. Another patient was discovered
dead and decomposing in a rooming house,
apparently following postabortal sepsis.
Arrested and charged with murder, Cream
was acquitted primarily due to the skill of his
defense attorney and the fact that the state’s
only witness was a “colored” lay midwife
who occasionally assisted him. After the
death of a third female patient under suspi-cious
circumstances, failed blackmail and
extortion schemes, a sordid libel attempt,
and the recent poisoning of his cuckold
patient noted above, Cream hurriedly left
Chicago and returned to Canada.
Within a month, he was arrested in Belle
Riviere, Ontario, taken to Windsor for ques-tioning,
and extradited to Chicago to stand
trial for the murder of his mistress’s hus-band.
He was again tried for murder, this
time convicted in September 1881 and sen-tenced
to life imprisonment in Joliet State
Prison with at least one day a year to be
spent in solitary confinement. Ten years
later, Illinois Governor Joseph W. Fifer
granted Cream executive clemency with
release in July 1891.
Returning to Canada and collecting a
modest inheritance, Cream then set sail
again for London where he took rooms
across the street from St. Thomas’s Hospital
but never again practiced medicine in the
traditional sense. He did represent himself
to acquaintances and potential victims as a
physician, even offering pills he compound-ed
himself for their various symptoms.
Cream quickly became a frequent customer
of the many prostitutes working nearby,
claiming multiple sexual encounters in an
evening, and was known to be obsessed with
pornography. He also became a regular user
of opium, morphia, cocaine, and beverage
alcohol to excess.
Following the deaths of two prostitutes
shortly after being seen with Cream, he once
more left town and sailed to Canada, but
returned to London after three months and
again took lodgings among its prostitutes in
the entertainment district. Two more of his
female acquaintances subsequently died of
arsenic poisoning. On 3 June 1892, he was
arrested by Scotland Yard on charges of
continued on page 17
REVIEW
“When a doctor goes wrong he is the first of
criminals. He has nerve and he has knowledge.”
Sir Arthur Conan Doyle
The Speckled Band, 1891
One of the earliest known serial killers was
Thomas Neill Cream, MD, hanged 15
November 1892 at age 42 years for the mur-der
(by surreptitiously giving them oral
arsenic represented as legitimate medication)
of four London prostitutes. Cream most
likely was responsible for the premeditated
murders by poisoning, either with arsenic or
chloroform, of at least five others in North
America, including his Canadian wife and
four of his U.S. patients, in addition to
untold London prostitutes. One of his
patients so dispatched was a paramour’s
elder husband and Cream intended to subse-quently
profit from an unsuccessful black-mail
scheme, threatening the victim’s phar-macist
with being revealed as the poisoner.
Cream was much more successful at murder
than extortion or blackmail.
Born 27 May 1850 in Glasgow, Scotland,
Cream emigrated with his family to
Montreal, Canada, in 1854, where his father
prospered in business and young Thomas
taught Sunday school. In March 1876, he
received, after four year’s study, the MD
degree from Quebec City’s McGill College,
presenting his graduation thesis on the phar-macological
properties of chloroform. The
occasion’s speaker addressed the graduates
on “The Evils of Malpractice in the Medical
Profession.”
Shortly after his graduation and prior to
sailing for England to continue his medical
Dr Harer
Doctor Death:
The Ultimately Impaired Physician
W. Benson Harer, Jr, MD, President
The American College of Obstetricians and Gynecologists
No. 3 2000 17
historian’s commitment to detail and
chronology. One shouldn’t be surprised, as
McLaren, professor of history at the
University of Victoria, Vancouver, British
Columbia, is an established author on schol-arly
topics both historical and social.
The second half is less like a yellowed,
dog-eared copy of an old Police Gazette or
New York Daily News, more interesting and
intellectually challenging as McLaren skill-fully
reweaves the fabric of life at the turn of
the century. That era’s women tried to con-trol
their fertility by using contraceptives or
seeking elective abortions, while various
moral and legal authorities simultaneously
tried to either aid or frustrate such efforts.
He describes law enforcement’s progression
from apprehension of criminals after the fact
to surveillance of potential perpetrators,
crime prevention, and, finally, actually pro-moting
crimes through enticement and
entrapment in order to make arrests. He
also explains how, during the late 1800s, rev-olutions
in cheap communication and trans-portation,
such as widely distributed period-icals,
reliable public mails, anonymous post
office box addresses, mimeographs, plus fast
steamships and trains, made both legitimate
and illegal activities more easily and effi-ciently
conducted. One hundred years later,
satellites, personal computers, the Internet,
and jet aviation have remarkably done the
same during the last 20 years of our century.
Suffragettes and other activists fighting
for the electoral, personal, legal, and proper-ty
rights of women, both married and single,
threatened an already unstable status quo.
Other studies of late 19th-century society
have focused on England, but Cream’s
exploits in Canada and the U.S. give us a dis-tinctly
American view of similar problems
for women on this side of the Atlantic.
Devout feminists will find much for justified
outrage here.
Our concepts of criminal behavior, moti-vation,
genesis, control, punishment, and
rehabilitation remain even today far from
providing effective preventatives. Dispari-ties
in legal and societal status of women
remain with us, as do prostitution and
exploitation. Women, especially prostitutes,
continue to be the prime victims of murder-ers,
rapists, assaulters, batterers, muggers,
and other violent criminals, with little pro-tection
except what they themselves provide.
Control of their sexuality and fertility
remains hotly and sometimes violently con-tested.
Serial murderers continue to own the
headlines on occasion. McLaren contends
that Cream and his crimes are best under-stood
as the products of an already sick Late
Victorian society and he won me over with
his arguments. Other readers may find alter-
Review
continued from page 16
nate explanations.
.........................
Reprinted with permission from The Medicolegal
OB/GYN Newsletter of The American Society of
Forensic Obstetricians and Gynecologists, PO
Box 536, Buckhannon, WV 26201-0536.
blackmail, on 18 July charged with murder
in the deaths of four prostitutes, during 17-
21 October tried by the Crown in Old Bailey
court rooms, on 21 October found guilty
after ten minutes’ deliberation by a jury of
his peers, immediately sentenced by the pre-siding
judge to be hanged by the neck until
dead and God’s mercy invoked on behalf of
his soul, and executed 15 November at
Newgate Prison.
–––––––––––––––––––––––––––
A Prescription for Murder: The Victorian
Serial Killings of Dr. Thomas Neill Cream
Angus McLaren
University of Chicago Press, Springer-
Verlag, Chicago, IL, 1993
233 pages (illustrated), $12.95 paperback
–––––––––––––––––––––––––––
In the finest police tradition, Scotland
Yard took full credit for the investigation and
arrest, yet McLaren clearly shows it was
Cream’s own hubris in calling attention to
the murders (first officially dismissed as sui-cides
or food poisonings), coupled with the
prostitute community’s coordinated and
persistent efforts to protect itself, that led to
his capture. McLaren has not written a
deep, psychological analysis of the serial
murderer’s criminal mind but instead an his-torical
and social analysis of moral, econom-ic,
and political conditions during the late
1800s which fostered or at least allowed
Cream’s professional failure, ever-deepening
descent into moral degradation, and eventu-ally
prolonged macabre crime spree.
The author examines quite well the role
society then demanded for women in gener-al,
prostitutes in particular, and the subse-quent
changes in its views of crime, law
enforcement, and the judicial system regard-ing
punishment of criminals and the status
of women. Since God dictated the Ten
Commandments to Moses, murder has been
recognized as the ultimate crime against per-sons,
with, over the last 150 years, serial
killers filling a special niche. Prostitutes have
always comprised a remarkably large num-ber
of their victims. Undoubtedly, society’s
attitudes toward commercialization of sex in
general and prostitutes in particular have
made their victimization much easier.
The first half of McLaren’s book, summa-rized
above, is a straightforward factual
account of Cream’s life, such as it was. It
avoids sensationalism, conjecture, and inter-pretation
as much as possible while holding
the reader’s attention with its well-written
Editor’s Note: The end of the 19th centu-ry
saw still another medical monster in the
person of Herman Webster Mudgett, who
renamed himself Harry Howard Holmes.
Born in Gilmanton, New Hampshire, in
1860, and trained at the University of
Michigan Medical School, he was to
become the first, and possibly the worst,
identified serial killer in U.S. history.
When finally caught, he admitted to
killing 28 people, but estimates are that he
murdered, and often mutilated, over 200,
mostly young women. He was hanged in
Philadelphia on May 7, 1896.
The end of the 20th century seems to
have joined the end of the 19th century in
fin de siecle horror. The crimes of Drs
Cream and Mudgett/Holmes have been
echoed in the careers of Britain’s Dr
Harold Shipman and our own Dr Michael
Swango. Dr Shipman was sentenced in
January 2000 to 15 terms of life in prison
for injecting elderly female patients with
fatal doses of heroin between 1995 and
1998. British police estimate that he may
have killed as many as 200 patients in the
same way over his 30 year career. That
would make him the worst serial killer in
British history.
Dr Michael Swango was immediately
arrested by New York authorities after his
recent release from prison, where he had
been serving time for lying on an applica-tion
for a position at a VA hospital. In
early September, he pled guilty to five
felonies, and admitted murdering four of
his patients through lethal injection and
attempting to kill four more. He was sen-tenced
to three consecutive life terms
without possibility of parole. He is sus-pected
of murdering 60 or more patients
during his medical career, which spanned
15 years and took him from Illinois, to
Ohio, to Virginia, to South Dakota, to
New York, and then to Zimbabwe. He
was on his way to another hospital job,
this time in Saudi Arabia, when he was
arrested in Chicago in 1997. His story is
told in chilling detail in James Stewart’s
book Blind Eye.
Sir Arthur Conan Doyle, a physician
himself, had it right.
18 NCMB Forum
Explore the NCMB’s Web Site:
www.ncmedboard.org
The North Carolina Medical Board’s Web site, www.ncmedboard.org, is a straightforward, content-based (no distracting bells and whistles)
source of useful information for the public, licensees, the media, and anyone else interested in the Board and its work. The Site Map below is
featured on the Web site and presents an easy to use guide to the topics covered on the site. Simply click on the Site Map bar in the menu at
the top of the home page, find the item you want on the map, then click – you’ll be there. Exploration couldn’t be easier. Among other things,
you’ll find forms that can be easily printed, the Forum and other publications, an electronic license registration system, information about indi-vidual
licensees, lists of current and past disciplinary actions, and details about the Board and its operation.
Improvements are being made continually to the Board’s site. New features and new information are added regularly. We hope you’ll explore
the site, using the Site Map as your guide, and take advantage of the resources it makes available. And, please, e-mail us your comments and
reactions (public.affairs@ncmedboard.org).
Site Map
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
See Consent Orders:
COBB, Timothy Lee, Physician Assistant
GROGAN, Patricia Jo, MD
ZABENKO, Robert Tracy, DO
SUMMARY SUSPENSIONS
NARA, David Alan, MD
Location: Hancock, MI
DOB: 4/28/1960
License #: 0000-39450
Specialty: GP (as reported by physician)
Medical Ed: Michigan State University (1986)
Cause: Dr Nara may be unable to practice medicine with reasonable skill
and safety by reason of illness, drunkenness, excessive use of alco-hol,
drugs, chemicals, or any other type of material within the
meaning of the statute.
Action: 6/14/2000. Order of Summary Suspension of License issued,
effective on delivery of the Order to Dr Nara. [Notice of
Charges and Allegations issued on 6/14/2000 alleging summary
suspension of Dr Nara’s medical license by the Michigan Board
based on allegations of alcohol abuse and self-prescribing of con-trolled
substances for other than lawful purposes.]
CONSENT ORDERS
COBB, Timothy Lee, Physician Assistant
Location: Yuma, AZ
DOB: 11/20/1948
License #: 0001-00183
PA Education:Duke University (1977)
Cause: Pursuant to an Agreed Order of 4/30/1999, the Texas PA Board
indefinitely suspended Mr Cobb’s Texas license based on his
diversion of certain controlled substances and his conviction for
felony fraudulent delivery of a prescription for a nonmedical pur-pose.
On 10/22/1999, the Texas Board stayed suspension of his
license for 10 years on terms and conditions.
Action: 6/15/2000. Consent Order executed: Mr Cobb’s North
Carolina PA license is suspended indefinitely; that suspension is
stayed for 10 years on condition he comply in all respects with
the Texas Agreed Order of 10/22/1999; must comply with other
conditions.
COHN, Gerald Herbert, MD
Location: Seattle, WA
DOB: 11/19/1928
License #: 0000-38916
Specialty: N/PD (as reported by physician)
Medical Ed: State University of New York, Upstate (1953)
Cause: On 12/19/1997, while preparing to perform a lumbar puncture,
Dr Cohn discharged into the face and eye of an observer a
syringe containing lidocaine through a needle that had just been
withdrawn from the back of a patient. Dr Cohn asserted the dis-charge
was accidental. Certain circumstantial evidence suggests
the act was intentional, while other circumstantial evidence sug-gests
it may not have been. Dr Cohn admits that if the Board
found the act was intentional, that would be immoral or dishon-orable
conduct and unprofessional conduct. He has met with
the Board, has been cooperative, and has seemed genuinely
remorseful for the damage his conduct caused. He no longer
performs lumbar punctures and will not do so in future unless all
persons present take adequate safety measures to protect against
injury and transmission of communicable disease.
Action: 5/12/2000. Consent Order executed: Dr Cohn is reprimanded.
GALEA, Lawrence Joseph, MD
Location: Charlotte, NC (Mecklenburg Co)
DOB: 10/19/1948
License #: 0000-27046
Specialty: FP/GP (as reported by physician)
Medical Ed: University of Cincinnati (1980)
Cause: To amend the Consent Order of 8/23/1999 by which Dr Galea’s
license was reinstated after having been inactive [for failure to
reregister]. The Board summarily suspended Dr Galea’s license
and, thereafter, entered into a Consent Order with him in
December 1991, which was amended in September 1992. He
was relieved of that Consent Order by a Board Order in May
1993. [Details of the earlier actions are available from the
Board.] The Board has agreed to modify the current Consent
Order to take account of his present practice and to make certain
requirements more specific.
Action: 7/21/2000. Consent Order executed: Dr Galea is issued a
license to expire on the date shown on the license (1/31/2001);
he shall submit to and cooperate with a psychological evaluation
and cause a report of that evaluation to be received by the Board
by 10/01/2000; nothing in this Consent Order prohibits or lim-its
the Board from taking any lawful action based on the results
of the evaluation; he shall renew his contract with the NCPHP
and abide by its terms; he shall maintain his NCPHP contract
until the Board orders otherwise; he shall have a female chaper-on
present during all of any encounter he has with a female
patient and the chaperon shall sign and date each patient’s chart,
noting her presence during the encounter; he shall not supervise
PAs, NPs, or nurse midwives in any way; he shall obtain 50
hours of relevant CME each year, 30 hours of which must be in
Category I; must comply with other conditions. The terms and
conditions in this Consent Order supersede those in the 1999
Consent Order imposing any continuing obligation or condition
on Dr Galea, except those imposing a reprimand and regarding
the public nature of the Consent Orders.
GOUBRAN, Michel Zaki, MD
Location: Durham, NC (Durham Co)
DOB: 2/15/1935
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program.
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May-June-July 2000
DEFINITIONS
No. 3 2000 19
License #: 0000-21039
Specialty: OBG (as reported by physician)
Medical Ed: University Ein Shams, Egypt (1962)
Cause: Dr Goubran admits and the Board finds Dr Goubran’s license
was suspended indefinitely pursuant to the Board’s Order of
April 27, 2000; the Board’s Order permits a stay of all but the
first six months of the suspension if Dr Goubran executes a con-sent
order with certain terms and conditions; Dr Goubran
desires to enter into this Consent Order and thereby stay the sus-pension
imposed by the Board’s Order.
Action: 5/24/2000. Consent Order executed: Dr Goubran admits the
findings of fact and conclusions of law set forth in the Board’s
Order, except he denies the stapling [of the medical student’s fin-ger]
was done intentionally; within 60 days of this Consent
Order, Dr Goubran shall obtain an assessment from the NCPHP
and cause a copy of the assessment to be sent to the Board; with-in
one year, he shall obtain at least 40 hours of CME in the areas
of epidemiology and infectious disease prevention, to be
approved in writing by the Board’s president; within one year, he
shall attend and successfully complete a sensitivity training
course, to be approved in writing by the Board’s president; must
comply with other conditions.
GROGAN, Patricia Jo, MD
Location: Smith River, CA
DOB: 7/05/1954
License #: 0000-34020
Specialty: P (as reported by physician)
Medical Ed: State University of New York, Brooklyn (1985)
Cause: This matter regards Dr Grogan’s interaction with patients. Dr
Grogan’s license is currently inactive and she is not interested in
reactivating her registration; during the times relevant to this
matter, she practiced in Pinehurst, NC. The Board received a
complaint from a patient that Dr Grogan engaged in various
boundary violations with the patient. These violations included
Dr Grogan having dinner with the patient in a restaurant and
afterwards the patient spending the night on Dr Grogan’s couch;
they also interacted socially at Dr Grogan’s invitation and Dr
Grogan disclosed personal information to the patient, changed
shirts in front of the patient in a public place, allowed the patient
to help clear her van and garage, and told the patient to call her
Patti. Dr Grogan denies some of this. Another patient com-plained
concerning other boundary violations: repeated requests
by Dr Grogan that the patient interact socially with her and her
children, a request that the patient come to Dr Grogan’s house
to administer homeopathic remedies to Dr Grogan for an
abscessed tooth, Dr Grogan accepting $120 from the patient so
she could obtain dental care, Dr Grogan prevailing on the patient
to search the Internet for prospective buyers for her medical
practice, Dr Grogan drinking beer during treatment sessions, and
Dr Grogan calling the patient at home to ask advice about per-sonal
problems. Dr Grogan denies some of this. Dr Grogan
admits she wrote a letter to the referring physician’s office admin-istrator
in which she disclosed confidential information about the
first patient without permission. She also admits she nursed one
of her children in front of male and female patients during vari-ous
treatment sessions; although at the time she believed the
patients consented to her doing this, she now understands that it
was unprofessional even if they consented. She also admits she
hired another patient to work in her office as an administrative
assistant.
Action: 6/22/2000. Consent Order executed: Dr Grogan’s license is sus-pended
for 60 days and the suspension is stayed for one year on
the following terms and conditions. Dr Grogan shall establish a
counseling relationship with an app